DDW-2024-007717

Fax to 801-536-4211, attn Drinking Water Source Protection staff

Use Waiver Application for:

Name of Water System_______ ____________________________________
Name of Drinking Water Source(s)___________________________

I, ________________________________________________, Designated Person (per R309-600) for the _________ Water System, hereby state that none of the volatile organic chemicals and/or
pesticides within the respective parameter groups have been used in, disposed of, stored in, transported through, or manufactured within protection zones one, two or three (or within
the management area, if applicable) in the last five years.

Signature:_______________________________________________
Date:_______________________________________________

Note: if applicable, you must provide a list of the chemicals used in, disposed of, stored in, transported through, or manufactured within protection zones one, two or three where the
use of such chemicals within the volatile organic chemicals and/or pesticide parameter groups is likely.

In general, the presence of residences or roads (other than very limited use roads) through zones one, two or three implies that pesticides and volatile organic chemicals are used, and
a use waiver in those cases would not be granted.