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DRINKING WATER CHAIN OF CUSTODY RECORD FOR RADIOLOGICAL PARAMETERS
6790 Kitimat Rd, Unit 4, Mississauga, Ontario L5N 5L9 www.maxxam.ca
Tel: 905-826-3080 Fax: 905-826-4151
*Please indicate which regulation applies to the samples being submitted:
170
Same as Invoice To
Attention:
Company Name:
Address:
Attention:
Project:
Address:
Fax:
P.O.#:
Tel:
Email:
ANALYSIS REQUESTED
Fax:
Email:
*DRINKING WATER TYPE LEGEND: [R=Raw Water] [T=Treated/POE] [D=Distribution]
Date Sampled
(YYYY/MM/DD)
Sample Identification/Location
Time
Sampled
*Water Type (R,T,D)
Report result
uncertainty?
Y/N
Resample Y/N?
# of
Bottles
Radium-226 (0.01 Bq/L)
Company Name:
Tritium (15 Bq/L)
Report To:
Gross Alpha/Beta (0.1 Bq/L)
Invoice To:
Tel:
Certificate of Approval Required
Not regulated (however water is for human consumption)
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*It is mandatory that all notification information marked with * be completed prior to analysis for regulated drinking water submissions.*
TAT (TURNAROUND TIME)
RUSH TAT MUST HAVE PRIOR APPROVAL
ADVERSE NOTIFICATION INFORMATION
Drinking Water System (DWS) information
*DWS Name:
Medical Officer of Health information
*Public Health Unit Name/Region:
Regular (10-15 Working Days)
*DWS Number:
RUSH (Specify Below)
*DWS Tel Number:
Contact Name:
DWS Address:
Address:
*DWS Contact Name:
*Tel #
*DWS Contact Tel:
*Fax #
DWS Contact Fax:
After hours #:
Date Due:
LABORATORY USE ONLY
Received By (Sign):
Date:
Time:
Comments:
Sampled By (Print):
Sampled By (Sign):
Date:
Time:
Relinquished By (Print):
Relinquished By (Sign):
Date:
Time:
BQL FCD-00080/2
Received By (Print):
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