DDW-2024-008035

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

Susceptibility 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 I am confident that a susceptibility
waiver for VOCs and/or pesticides will not threaten public health.

Signature:_______________________________________________
Date:_______________________________________________

Note: We must have a record of the monitoring results of at least one sample from the VOC and/or pesticide parameter group taken in the last five years. A non-detect result is required.

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