DDW-2024-010951

Utah Division of Drinking Water
IPS Deficiency Correction Notice
Water System Name_________________________________________________
Water System ID #UTAH________
Instructions
Please use this form to report the correction of sanitary survey deficiencies identified on your
IPS report. List the individual Facility ID (where applicable), deficiency code, how deficiency
was corrected and the date of the correction below. You may attach a copy of your IPS report
with the date of the correction noted on the report. Pictures of corrections or a brief description
of the corrections are encouraged. Include the name of the facility and the correction date on any
documentation you provide.
Facility ID Deficiency Code How deficiency was corrected Date Corrected

I certify that the information submitted with this report is true and accurate. You may
electronically sign this form by typing your name in the Signature block.
Print Name Signature Date
Corrections listed on attached IPS report Supportive documentation attached
DDW Approval______________________________________ Date_____/_____/_____
Print Form
18026
ST029 Ladder installed and secured Sep 9, 2024
Sep 9, 2024Teresa Gray
Salt Lake City Water System
Submit by Email
V004