Notice to Operate or Re-open a Small Drinking Water System

Submit the form at least 14 days prior to proposed opening.

This is to notify the Medical Officer of Health of the intent to supply water to the users of the following Small Drinking Water System before operation or after a shut down when water has not been supplied to users for more than 60 days as required under Ontario Regulation 319/08 Small Drinking Water Systems.

Section 1: Small Drinking Water System (SDWS) Information

SDWS Information

SDWS Name

System Number

Address

City/Municipality

Postal Code

The SDWS is:

Date of proposed opening

Water samples are required prior to water being offered to users after a period of closure.

Sample results attached

Attach sample results, if available.

One file only.
2 MB limit.
Allowed types: jpg png txt pdf doc docx ppt .

Owner Information

Name of legal Entity

Address

City/Municipality

Postal Code

Phone Number

Email Address

Section 2 - Responsibilities of Owners and Operators

O. Reg. 319/08, s. 6(1) requires the owner of a Small Drinking Water System to designate an operator who has primary responsibility to fulfill the requirements of all sampling, testing, receipt of results, and submission of reports.

Designated Operator Information

Operator Name

Address

City/Municipality

Postal code

Email Address

Declaration Owner

I acknowledge, whether acting as the owner or as a partner/president/signing officer representing the owner, acknowledge that the information provided in this form is accurate and complete. According to the Health Protection and Promotion Act, an operator is defined as the individual(s) responsible for overseeing activities at the Small Drinking Water System. It should be noted that there may be more than one operator at a Small Drinking Water System. The person identified above as the operator for the specified Small Drinking Water System holds primary responsibility for fulfilling the duties of the operator, including sampling, testing, receiving results, and submitting report.

Owner

Re-order	First and Last name	Date	Weight	Operations
	First and Last name	Date	Item weight

more items

Owner is designated operator

Declaration Operator

I acknowledge that the owner has entrusted me with primary responsibilities for carrying out the operator's duties related to sampling, testing, receiving results, and submitting reports for this small drinking water system.

Operator

Re-order	First and Last Name	Date	Weight	Operations
	First and Last Name	Date	Item weight

more items

The information on this form is collected under the authority of the Health Protection and Promotion Act in accordance with the Municipal Freedom of Information and Protection of Privacy Act and the Personal Health Information Protection Act. This information will be used for the delivery of public health programs and services; the administration of the agency; and the maintenance of healthcare databases, registries and related research, in compliance with legal and regulatory requirements. Any questions about the collection of this information should be addressed to the Chief Privacy Officer at 1-800-265-7293 ext 4339.

Notice to Operate or Re-open a Small Drinking Water System

SDWS Information

Owner Information

Designated Operator Information

Declaration Owner

Declaration Operator

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