DDW-2024-008792

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.
.