HomeMy WebLinkAboutDDW-2024-011492
Utah Department of Environmental Quality Division of Drinking Water
Safe Drinking Water Program Sanitary Survey Review and Related Enforcement Report
Prepared by:
U.S. Environmental Protection Agency, Region 8
Enforcement and Compliance Assurance Division SDWA Enforcement Section
September 19, 2024
SDWA PWSS Sanitary Survey Review: Utah
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SDWA PWSS Sanitary Survey Review: Utah
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Table of Contents
Executive Summary ...................................................................................................................4
I.Introduction .......................................................................................................................5
A.Background and Purpose of Evaluation .........................................................................5
B.Data Evaluated ...............................................................................................................6
C.Description of Review Activities ...................................................................................7
II.Sanitary Survey Review Evaluation .................................................................................7
A.Timing and Frequency of Surveys and Timely Notification to PWS of Significant
Deficiencies....................................................................................................................9
B.Report Format ..............................................................................................................10
C.Identification of Significant Deficiencies and Violations ............................................11
D.Monitoring of Corrective Actions to Significant Deficiencies ....................................12
E.Evaluation of Treatment Technique Violations and Associated Follow-Up ...............14
III.Recommendations, Best Practices and Conclusion ........................................................16
Appendix A: Large Public Water Systems for this Review ...................................................18
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Executive Summary Objective: The US Environmental Protection Agency (EPA) has delegated authority to implement the Safe Drinking Water Act (SDWA) Public Water System Supervision (PWSS)
program to the Utah Department of Environmental Quality (UDEQ). As part of the EPA’s oversight responsibilities, staff from the EPA Region 8’s Enforcement and Compliance Assurance Division conducted an evaluation of 50 sanitary surveys across 24 large community and 1 non-community water systems where at least one of the two most recent sanitary surveys identified at least one significant deficiency. The purpose of this review was to assess the
thoroughness of the sanitary surveys and related enforcement actions conducted by the UDEQ. Public water systems were selected for sanitary survey review in January 2024 and this evaluation was conducted in February 2024 through July 2024. The evaluation assessed whether sanitary surveys were in alignment with state and federal regulations, policies, and procedures and evaluated the implementation and management of follow-up actions related to significant
deficiencies identified, including enforcement where appropriate. The evaluation was conducted remotely and included relevant files provided electronically by the UDEQ management, the EPA ECHO database, and information collected during interviews with the UDEQ management and staff.
Below is a table summarizing this report including the components reviewed, the results of the review, and the applicable references.
Summary Categories Results Notes Reference
Surveys conducted within 3 sanitary survey season target 24/25 (96%)
Average: 3 seasons Range: 2 – 4 seasons 40 CFR §142.16(o)(2)(i)
Sanitary survey report sent to system within 30 days of survey
Note: Requirement for ground water systems (GW) only
22/22 reports (100%) for GW systems
25/28 reports (89%) for SW,
SWP, and GU systems
Average GW:13 days Range GW: 0 - 30 days
Average SW/SWP/GU: 19 days Range SW/SWP/GU: 2-56 days
40 CFR §142.16(o)(2)(v)
All eight elements reviewed 50/50 (100%) All surveys conducted utilizing UDEQ approved checklist 40 CFR §141.401(c)
Surveys with at least one significant deficiency (SD) 32/50 (64%) Average: 4 SDs Range: 0 - 30 significant Deficiencies
Final reports with significant deficiencies that requested a 30/45-day response
50/50 (100%) 40 CFR §142.16(o)(2)(v) and §142.16(b)(1)(ii)
Surveys where significant deficiencies resolved without a Corrective Action Plan (CAP)
21/32 (65%) 40 CFR § 141.404
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Surveys with significant deficiencies resolved with a CAP
11/32 (35%) 40 CFR § 141.404
Days from report to correction of all significant deficiencies with CAP
Average: 357 days Range: 243 - 550 days 40 CFR § 141.404
Number of surveys with significant deficiencies where significant deficiencies not timely corrected
8/32 (25%)
If significant deficiencies not
timely addressed, number of treatment technique violations issued
2/8 All treatment technique
violations returned to compliance at time of report
If significant deficiencies not timely addressed, number of deficiencies unaddressed at time of review
0/8 The six violations that did not become treatment technique violations all returned to compliance, just after the 120-day deadline but before a violation was issued
40 CFR § 141.404 40 CFR §142.16(b)(1)
I. Introduction
A. Background and Purpose of Evaluation The PWSS program was established by the EPA under the authority of SDWA. The PWSS program implements and enforces the requirements of SDWA that apply to public water systems.
The goal of the PWSS program is to ensure that public water systems comply with the National
Primary Drinking Water Regulations listed in 40 CFR §141. SDWA allows states, tribes, and territories to seek the EPA’s approval to administer their own PWSS program and the authority to run a PWSS program is called primacy. In circumstances where states, federally recognized tribes and U.S. territories do not have primacy, regulatory authority stays with the EPA under a
Direct Implementation program. When the EPA has approved a state, tribe, or U.S. territory to
administer their own program, one of the EPA’s primary missions is to conduct oversight of the primacy agencies as they implement the program. The PWSS program is a data-driven, self-reporting and largely self-regulating program.
Accuracy in reporting is essential for a primacy agency to make compliance determinations.
Each quarter, primacy agencies are required to submit data to the Federal Safe Drinking Water Information System (SDWIS/FED), an automated database maintained by the EPA. The data submitted to SDWIS/FED include, but are not limited to, inventory information about a public water system, sampling results when the monitoring results exceed the Maximum Contaminant
Level (MCL), violation information for a public water system (PWS), and enforcement actions
taken by the primacy agency to ensure that a public water system returns to compliance.
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The UDEQ has primary enforcement responsibility under Section 1413(a) of SDWA, 42 USC §300g-2(a), to ensure that suppliers of potable water within the state of Utah comply with the
requirements of SDWA, with amendments pursuant to the Utah Safe Drinking Water Act (Title
19, Chapter 4 of the Utah Code) and Utah Rule R309-200, Drinking Water Standards. Utah’s Drinking Water Program is housed within the UDEQ’s Division of Drinking Water. It is comprised of six sections: Field Services Section, Administrative Services, Water
Quality/Monitoring Standards, Compliance and Operator Assistance, Infrastructure Funding, and
Permitting. For the purposes of this evaluation, the EPA’s collaboration was with representatives from the Field Services Section, which implements the sanitary survey program including conducting surveys and inspections, and the Compliance and Operator Assistance Section, which determines violations, maintains the public water system inventory, violation, and enforcement
database, and tracks formal and information enforcement actions.
Utah has a current universe of 1060 public water systems. There are 506 community water systems (CWS). 63 CWSs serve a population between 10,001-100,000 and 5 serve a population greater than 100,000, for a total of 68 CWS serving populations over 10,000 defined by this
report as large CWSs. The UDEQ conducts the sanitary surveys directly for all public water
systems in Utah. The UDEQ maintains and tracks Utah drinking water data and information, including data on significant deficiencies, in SDWIS State. UDEQ maintains a public facing version of their
SDWIS State searchable by water system on their website allowing the public to obtain data
about their water system and compliance status with both federal and state requirements at any time. The UDEQ is to be commended for making public water system records and sample results available to the public online.
This EPA review of State sanitary surveys at large CWSs is part of the EPA’s National
Compliance and Enforcement Initiative: Increasing Compliance with Drinking Water Standards. Goal 1 of the NCI is to Ensure clean and safe water by improving compliance at Community Water Systems regulated under SDWA. Measure 1.4 under Goal 1 is to Evaluate and, if necessary, address by the end of FY2027 50% of the CWSs serving over 10,000 people to ensure
compliance with NPDWRs.
B. Data Evaluated The EPA selected the 25 large CWSs for this review in January 2023 based on a pull of data
from SDWIS/Fed associated with the January 2023 Enforcement Targeting Tool, or ETT. This
data pull was designed to distinguish large CWSs where there was at least one significant deficiency identified during at least one of the two most recent sanitary surveys. Surveys with significant deficiencies were of interest due to the enforcement component of this review. Ten systems were ground water systems, one system was a groundwater purchasing system, one
system was a ground water under the direct influence of surface water system, five were surface
water systems, and eight were surface water purchasing systems. The EPA evaluated the two most recent sanitary surveys for these 25 large CWSs, for a total of 50 sanitary surveys. Thus, this is a targeted review of sanitary surveys at large CWSs with significant deficiencies and is not
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representative of sanitary survey reports from all large CWSs in Utah.
The list of 25 large CWSs for review was shared with the UDEQ, which then provided the EPA
with data for each of the large CWSs that included sanitary survey data pulled from the UDEQ’s public water system database and internal sanitary survey and significant deficiency tracking tools. In January 2024, when the data was pulled that identified the 25 CWSs for this review, all 25 CWSs had at least one significant deficiency over the past two most recent surveys based on
data in UDEQ’s database. C. Description of Review Activities The EPA reviewed the two most recent sanitary surveys for each of the 25 selected public water
systems, provided by UDEQ. The EPA also reviewed other relevant sanitary survey records from
UDEQ, including Corrective Action Plans for significant deficiencies, Sanitary Survey Response Forms and documentation of completed corrective actions. The EPA reviewed the spreadsheets of each public water system’s inventory and sanitary survey and significant deficiency data provided by the UDEQ as well as EPA’s ECHO Detailed Facility Reports. The EPA also met
with Ryan Dearing, Michelle Deras, Brian Pattee, and Colt Smith at the beginning of the effort to
go through the UDEQ Sanitary Survey and Enforcement Programs. The EPA reviewed Utah’s Rule R309-200, Drinking Water Standards, sanitary survey checklists, deficiency checklists, UDEQ’s Corrective Action Plan SOP, the IPS/Deficiencies Groundwater
Rule (GWR) SOP/Policy draft document, the rating criteria used to determine PWS’ ratings, and
other drinking water resources for water systems developed by the UDEQ.
II. Sanitary Survey Review Evaluation The EPA has posted information and hyperlinks on federal requirements and guidance regarding sanitary surveys on its Sanitary Survey website1. Sanitary survey regulatory requirements for States are found at 40 CFR § 142.14-162. Sanitary survey regulatory requirements for public
water systems are found at 40 CFR § 141.4013 and § 141.7234. The EPA guidance documents and reference material for sanitary surveys include the Sanitary Survey Guidance Manual for Ground Water Systems5 (Guidance Manual) dated October 2008 and the How to Conduct a Sanitary Survey of Drinking Water Systems: A Learner’s Guide6 (Learner’s Guide) dated August 2019. The Learner’s Guide is a comprehensive document used for training purposes and covers
1 https://www.epa.gov/dwreginfo/sanitary-surveys 2 https://www.ecfr.gov/current/title-40/chapter-I/subchapter-D/part-142#142.14 3 https://www.ecfr.gov/current/title-40/chapter-I/subchapter-D/part-141#141.401 4 https://www.ecfr.gov/current/title-40/chapter-I/subchapter-D/part-141#141.723 5 https://www.epa.gov/sites/default/files/2016-12/documents/gwr_sanitary_survey_guidance.pdf 6 https://www.epa.gov/sites/default/files/2019-08/documents/sanitary_survey_learners_guide_508_8.27.19.pdf
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sanitary surveys for ground water systems, surface water systems, and systems with ground water under the direct influence of surface water (GWUDI).
With the regulations, Guidance Manual and Learner’s Guide as primary sources for reference, the EPA evaluated the following aspects:
Timing and frequency of sanitary surveys and timely notification to PWSs of significant
deficiencies;
Proper report format;
Identification of significant deficiencies;
Monitoring of significant deficiency corrective actions; and
Evaluation of treatment technique violations and associated follow-up actions.
In accordance with 40 CFR § 142.10(b)(2), primacy agencies are required to have a systematic program for conducting sanitary surveys of public water systems, with priority given to sanitary surveys of public water systems not in compliance with primary drinking water regulations. Primacy agencies must conduct sanitary surveys every three or five years, depending on the type
of public water system, the type of water source for the system and previous significant
deficiency status. Ground water systems may be designated as outstanding performers based on criteria developed by the primacy agency. Sanitary surveys need to be conducted once every five years for outstanding performers. For this report, timing was evaluated using UDEQ’s applied sanitary survey season (season) of April to October of each year. The seasonal approach allows
that all sources are accessible and seasonal systems are active when the surveys are conducted.
Sanitary surveys must include an evaluation of the following eight components: 1) source; 2) treatment; 3) distribution system; 4) finished water storage; 5) pumps, pump facilities, and controls; 6) monitoring, reporting and data verification; 7) system management and operation;
and 8) operator compliance with State requirements. During a survey, the surveyor may
encounter a “significant deficiency”, which is any serious sanitary defect in a system’s design, operation, and maintenance, or a failure or malfunction of the sources, treatment, storage, or distribution system that the primacy agency determines to be causing, or has the potential to cause, the introduction of contamination into the water.
The UDEQ also identifies violations of the State’s Utah Safe Drinking Water Act during sanitary surveys. Thus, the sanitary survey also serves as an inspection. Such violations are Tier 2 or Tier 3 violations and require a public notice. All Corrective Action Plans (CAPs) approved by the state have a cover letter with a reminder that failing to comply with the CAP will result in a
treatment technique violation and will require the appropriate Public Notice. UDEQ uses a
standard checklist for all surveys that is broken down by asset (and asset subtypes for treatment plants) to ensure that every portion of the system is reviewed. The checklist identifies recommendations and minor and significant deficiencies through very specific and detailed requirements for each asset. This checklist ensures that regardless of water system size, all assets
are reviewed, and all significant deficiencies are captured. The checklists received for this effort
ranged from 18 to over 300 pages, depending on system size and number of assets. The UDEQ is commended for their thorough checklists that guide both new and experienced reviewers to appropriately issue significant deficiencies.
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A. Timing and Frequency of Surveys and Timely Notification to PWS of Significant
Deficiencies In accordance with SDWA, 40 CFR §142.16(o)(2)(i), a primacy agency must conduct sanitary surveys that address the eight sanitary survey components no less frequently than every three or five years as explained above. Complete reports must be provided to water system owners and/or
operators in a timely manner. 40 CFR §142.16(o)(2)(v) requires primacy agencies to provide
ground water systems with written notice describing any significant deficiencies no later than 30 days after the primacy agency identifies a significant deficiency. UDEQ conducts sanitary surveys using a season from April to October of each year, due to winter conditions that limit access to drinking water sources and seasonal systems that are not open year-round.
Findings:
Surveys conducted within 3-fiscal year target 24/25 (96%)
Average: 3 sanitary survey seasons Range: 2-4 sanitary survey seasons
Sanitary survey report sent to ground
water systems within 30 days of survey
Note: Requirement for ground water
systems (GW) only. UDEQ endeavors to issue all sanitary survey reports to systems within 30 days of survey.
22/22 reports (100%) for
GW systems
25/28 reports (89%) for SW, SWP, and GU systems
Average GW:13 days
Range GW: 0 - 30 days Average SW/SWP/GU: 19 days
Range SW/SWP/GU: 2-56 days
During this evaluation, the EPA found that the UDEQ staff conducted sanitary surveys at the prescribed frequencies listed above for 96% of the reviewed systems. UDEQ’s Fiscal Year runs from July 1 to June 30th. However, EPA evaluated the program using UDEQ’s sanitary survey season which is implemented due to challenges of access to drinking water sources and seasonal
systems. UDEQ uses the seasonal system to ensure all every source can be included in the
survey, and systems are inspected while they are actively serving water to the public. Therefore, a sanitary survey conducted during one season (e.g., FY2018) would need to be rescheduled within 3 seasons (e.g., FY2021). EPA identified the season for each sanitary survey reviewed and, for each system, calculated the number of seasons between sanitary surveys. One large
community water system had greater than three seasons between surveys and is presented in the
table below:
Public Water System Name PWS ID Survey Year Next Consecutive Survey Year
Years Between Surveys
CEDAR CITY WATERWORKS UTAH11002 2018 2022 4
Documentation provided by UDEQ indicated that the Sanitary Survey for Cedar City Waterworks was deferred due to site visits to the system to perform a Level 2 Assessment required per the Revised Total Coliform Rule. The Level 2 Assessment in use by UDEQ can
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include all eight elements of a sanitary survey but all eight elements are not required to be evaluated during each Level 2 Assessment. The elements for review are determined based on the
details of each individual case. The Level 2 Assessment was performed on September 2, 2020,
but did not include all of the eight elements required for a sanitary survey. The requirement to provide a sanitary survey report to the system within 30 days applies to ground water systems only. 40 CFR § 142.16(o)(2)(v) requires primacy agencies to provide
ground water systems with written notice describing any significant deficiencies no later than 30
days after the primacy agency identifies a significant deficiency. The majority of large CWSs are supplied by surface water, not ground water. There were eleven ground water systems with twenty-two sanitary surveys that were part of this review. All 22 sanitary survey reports, or 100%, were provided to the systems in 30 days or less. For ground water systems, the average
turnaround time was 13 days with the longest at 30 days and the shortest at 0 (same day) days.
There were 14 systems that were surface water, surface water purchased, or ground water under the direct influence of surface water. Looking at these non-ground water systems, for which the 30-day turn-around time is a goal but not a requirement, 25 sanitary surveys reports, or 89%,
were provided to the system in 30 days or less from the date of the sanitary survey. Only 3
sanitary survey reports were provided to the system more than 1 month after the sanitary survey and none were provided over 2 months after. For non-ground water systems, the average turnaround time was 19 days. The longest report turnaround time was 56 days, and the shortest turnaround was 2 days. The timeliness of sanitary survey reports issued to non-ground water
systems is commendable considering the challenge of preparing reports for large public water
systems, several of which required multiple days to complete the sanitary survey. UDEQ displayed excellence in their fast and thorough communications following sanitary surveys.
B. Report Format
According to the Guidance Manual, sanitary survey reports are final written reports that are used to notify PWSs of the survey results, identify deficiencies and recommendations for improvement, and assist in facilitating corrective action as needed. The Guidance Manual states that reports should be prepared in a format that is consistent statewide and appropriate
documentation should be completed to support follow-up activities and for report development.
The Guidance Manual also states that a sanitary survey report includes a copy of a completed survey form or checklist for the water system, if used. Findings:
Surveys where all eight elements reviewed
50/50 (100%)
Final reports with significant deficiencies that requested a 30/45-day response 50/50 (100%)
The UDEQ has standardized sanitary survey report templates that are used by all staff conducting sanitary surveys, which creates a standard format for all reports. The report format presents findings of the sanitary survey, including the following: dates and parties present;
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notification that a response is due within 30 days; table of sanitary survey findings for significant deficiencies, minor deficiencies, and observations-recommendations; and detailed description of
each significant deficiency, violations and observations/recommendations. The UDEQ’s sanitary
survey reports templates and accompanying cover email/letter were well written and easy to understand. For this measure, the EPA obtained and reviewed copies of sanitary survey reports from UDEQ.
Based on the review of this information and the accompanying spreadsheet from UDEQ, all 8
elements were evaluated during the sanitary surveys per their standard checklist process. These records also documented the status of each asset or question per element, and were summarized in the accompanying sheet highlighting recommendations, minor deficiencies, and significant deficiencies.
For the 50 sanitary survey reports reviewed, all 50 reports or 100% requested a written response from the system in 30 days if a significant deficiency or deficiencies had been identified.
C. Identification of Significant Deficiencies and Violations
The EPA Guidance Manual states that when a deficiency is identified, the report should include the following elements: - detail to provide the PWS with enough information on what deficiencies exist;
- what corrective actions are needed; - why the corrective actions are necessary; - compliance schedules or requests for a correction date; and - for any significant deficiencies, the Groundwater Rule requires a State-approved compliance schedule for significant deficiencies that are not corrected within 120 days of
being identified by the primacy agency. Findings:
Surveys with at least one significant deficiency 32/50 (64%) Average: 4 significant deficiencies Range: 0 - 30 significant deficiencies
The EPA found that 32 of the 50 sanitary surveys reviewed (64%) reported at least one significant deficiency. The average number of significant deficiencies per survey for the large CWSs selected for this review was four, ranging from no significant deficiencies to high of 30 significant deficiencies. The 30 significant deficiencies were identified at Salt Lake City Water
System (UTAH18026), during the 2020 sanitary survey. A CAP was issued to address the significant
deficiencies that were not addressed or given an exception, and all were corrected. For this same system, 7 significant deficiencies were identified in the most recent 2023 sanitary survey, and all were addressed on time without the need for a CAP. This demonstrates UDEQ’s thorough review of large systems using the checklist ensuring that all assets are reviewed. The checklists
were both over 300 pages for both sanitary survey years.
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It is important to note that CWS serving 10,000 or more with recorded significant deficiencies were targeted for this effort. Therefore, we expect to see a large number of surveys containing
significant deficiencies in relation to the universe of systems UDEQ oversees. Many systems
also had minor deficiencies or recommendations which are similarly highlighted in the report’s cover page.
D. Monitoring of Corrective Actions to Significant Deficiencies According to 40 CFR § 141.404(a), a PWS using ground water has 120 days to correct significant deficiencies identified during a sanitary survey. If corrective action will not be
completed within 120 days, the system is required to contact the state within 30 days of receiving
notice of the significant deficiency for a consultation and develop an approved schedule to correct the deficiencies, referred to as a Corrective Action Plan (CAP). If a system is unable to complete corrective action in 120 days, fails to consult with the state on an approved corrective action plan within 30 days, or fails to implement the corrective actions on the schedule agreed
upon by the State, then the system is in violation of the treatment technique requirement. Pursuant to 40 CFR § 142.16(b)(1)(ii), a PWS using a surface water source or a ground water source under direct influence of surface water has 45 days from notification to respond to the state regarding any identified significant deficiencies. Sanitary survey reports should provide clear language to guide systems in how to respond accordingly.
It is critical to a well-functioning sanitary survey program for primacy agencies to monitor PWSs to ensure that significant deficiencies and/or recommendations are timely and appropriately addressed, and that significant deficiencies and associated corrective actions are sufficiently documented.
Based on the records provided by UDEQ, and data available in SDWIS Fed, EPA could examine if a CAP was issued, associated milestones, and if violations were issued for failing to either request a CAP or violating an approved CAP.
Findings:
Sanitary survey reports with significant deficiencies that requested a 45-day written response
50/50 (100%)
Surveys where significant deficiencies resolved without a CAP 21/32 (65%)
Surveys with significant deficiencies resolved with CAP
11/50 (36%)
Thirty-two of the 50 sanitary surveys reviewed resulted in the finding of at least one significant deficiency. All sanitary survey reports with significant deficiencies requested a response within the regulated timeline applicable for ground water or surface water systems.
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Of the 32 sanitary surveys reviewed with at least one significant deficiency, 21 or 65% were resolved without a CAP. The average number of days from the sanitary survey report to
correction of all significant deficiencies without a CAP is unknown as that data is tracked in
UDEQ’s SDWIS State database but is not transferred to the SDWIS Fed database for EPA to review. UDEQ reported to EPA that seven sanitary surveys had significant deficiencies that were not corrected within the 120-day time frame. Of these, most were corrected prior to violation issuance through technical assistance from UDEQ, and others were issued a treatment technique
violation, as discussed below.
There were 11 sanitary surveys (35%) where significant deficiencies were resolved with a CAP. Of these 11, three had an extension to the CAP as noted below and zero had the CAP extended more than once. UDEQ did note on occasion that some of the deficiencies were corrected after
the deadline but before a violation could be issued. The average number of days from the
sanitary survey report to correction of all significant deficiencies with a CAP was 405 days, ranging from 243 days to a high of 740 days. The University of Utah CAP timeline, denoted with an * below, was not factored into the average since UDEQ noted that the deficiency was later determined to not be correct and was returned to compliance without any action needed from the
system.
Below is a list of all survey’s reviewed that were resolved with a CAP or have a CAP with ongoing due dates at the time of this review.
Public Water System Name PWS ID Sanitary Survey Report Date CAP Extended
Days to Correction
CEDAR CITY WATERWORKS UTAH11002 10/2/2018 Yes 324
SALT LAKE CITY WATER SYSTEM UTAH18026 10/21/2020 Yes 740
JORDAN VALLEY WCD UTAH18027 7/6/2018 No 243
UNIVERSITY OF UTAH UTAH18057 10/28/2020 Yes 1160* HERRIMAN CITY MUNICIPAL WATER DEPARTMENT UTAH18157 8/7/2020 No 298
LINDON CITY UTAH25016 7/6/2022 Yes 550
PLEASANT GROVE CITY UTAH25022 9/14/2022 No 388
SARATOGA SPRINGS CITY UTAH25138 10/26/2020 No 365
IVINS UTAH27008 11/28/2018 No 335
The office of the Utah Legislative Auditor General conducted an internal investigation of certain
divisions within the Department of Environmental Quality, including the Division of Drinking
Water, regarding inspections and follow up actions. The internal report found that UDEQ needed to improve in cases where water systems were not correcting deficiencies7. However, their results also noted that larger systems typically resolved their deficiencies faster than smaller
7 An In-Depth Budget Review of the Department of Environmental Quality (August 2020) Office of the Legislative Auditor General, State of
Utah. 2020-04 UT Internal Audit Report DEQ
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water systems and that the majority of water systems in Utah serve less than 500 people. Therefore, it is somewhat difficult to compare the results of this evaluation, which is considering
only systems that serve greater than 10,000, with the internal review conducted by the state of
Utah. The internal review was detailed and has led to the implementation of some new processes to address the findings of the report. We applaud DEQ and the office of the State Legislative Auditor General for completing a thorough internal review of the sanitary survey process and for implementing changes to address the findings.
E. Evaluation of Treatment Technique Violations and Associated Follow-
Up According to 40 CFR §141.404(a) a treatment technique violation has occurred if a ground water
system fails to resolve a significant deficiency discovered during a sanitary survey within 120-
days of the discovery or within a deadline mutually agreed upon in a CAP negotiated between the State and the system. According to 40 CFR § 142.16(b)(1), a treatment technique violation has occurred if a surface water system fails to respond within 45 days of being notified of a significant deficiency, in writing to the State, with an agreeable schedule to address the
deficiency or fails to resolve the significant deficiency within a deadline mutually agreed upon in a CAP negotiated between the State and the system. The EPA has established guidelines regarding the content of SDWA formal enforcement actions.
According to the EPA’s 2009 Drinking Water Enforcement Response Policy (2009 ERP)8,
formal enforcement actions are required to have the following components: a description of the violation; citation of the applicable State or federal law/rule; a compliance schedule and return-to-compliance date; statement of what is needed to return to compliance; and the regulatory agency’s authority to impose penalties for violation of the formal enforcement action document.
The intent of a formal enforcement action is to bring non-compliant PWSs back into compliance
by a certain date with enforceable consequences if the schedule is not met. The 2009 ERP also established the Enforcement Targeting Tool (ETT), a tool that pulls data from SDWIS/FED to determine enforcement priorities. The ETT assigns point values for
different types of violations. The 2009 ERP states that systems with an ETT score of 11 or higher
are considered priority for enforcement and should return to compliance or be issued an appropriate formal enforcement action. In addition to the EPA ERP, the state of Utah has a rating system used to define the rate of every
water system the UDEQ oversees. Each significant deficiency is assigned a point value, and
unaddressed significant deficiency can negatively impact the system’s rating. If a system is downgraded from approved to not approved for 6 months, the system will either enter a bilateral agreement for corrections or will be evaluated for an Administrative Order. This allows UDEQ to target systems that have multiple significant deficiencies that are unaddressed stemming from
the same sanitary survey (treatment technique violations that would be entered into the database
with the same compliance period begin dates), instead of relying solely on the point system
8 EPA Memorandum: Drinking Water Enforcement Response Policy. 8 2009. https://www.epa.gov/sites/production/files/documents/drinking_water_erp_2009.pdf
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through the ETT where these violations would be grouped into one 5-point violation. Therefore, systems with multiple significant deficiencies that are not addressed within the required
timeframe of 120-days or through a UDEQ approved CAP, can be prioritized for further action.
Findings:
Number of surveys with significant deficiencies where significant deficiencies not timely corrected
and a violation was issued
2/32 (6%)
If significant deficiencies not timely addressed, amount of time before violations were entered into SDWIS
37 days after CAP deadline passed (University of Utah)
43 days after 120-days passed (Pleasant Grove City)
Time Between violation issuance and return to compliance 300 days for University of Utah*
59 days for Pleasant Grove City
Of the 32 surveys reviewed as part of this evaluation where the survey resulted in the finding of
at least one significant deficiency, the EPA evaluated whether significant deficiencies were corrected by the corresponding due date, with submissions documenting completed corrective actions made to UDEQ by the due date and with submitted documents reviewed and decisions regarding approval made within a reasonable amount of time. There were two sanitary surveys
conducted at two public water systems where at least one significant deficiency was not
corrected by the due date nor was a submission of documentation of completed corrective actions made to UDEQ near the due date. Thus, there were two Treatment Technique violations entered into SDWIS Fed for failure to address the significant deficiencies by the required dates. These are described below. There are two additional treatment technique violations included in the
table below that were not reviewed as part of this effort but were issued to the systems included
in review. *The University of Utah’s significant deficiency was later determined to have been issued in error and was returned to compliance without further action. The significant deficiency was
included in the analysis because it was not rejected or deleted from SDWIS Fed and, therefore,
recorded as a valid violation that was returned to compliance. Public Water System Name PWS ID Source Type Survey Report Date Compliance Period Begin Date Return to Compliance Date
HOLLIDAY
WATER COMPANY
UTAH18010 SWP Previous
sanitary survey not reviewed during this effort
2/1/2017 4/20/2020
UNIVERSITY
OF UTAH
UTAH18057 GWP 10/15/2020 3/23/2022* 1/3/2024
PLEASANT GROVE CITY UTAH25022 GW 8/24/2022 2/11/2023 4/10/2023
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NORTH OGDEN CITY UTAH29010 GW Previous sanitary survey not reviewed
during this effort
1/12/2018 12/12/2019
III. Recommendations, Best Practices and Conclusion
The EPA appreciates the time and effort of the UDEQ mangers and staff in providing the
requested information and for timely, consistent communication throughout this evaluation
process. The EPA recognizes that information, including the status of significant deficiencies and/or related enforcement actions, may have been updated between the time the sanitary survey status was reviewed and the finalization of this report. All recommendations are applicable to the information provided during the identified review period and are directly correlated to the
information made available at the time of this review.
The EPA identified some discrepancies and offers recommendations related to the UDEQ sanitary survey procedures, reporting of sanitary survey results and the follow-up action taken in response to identified deficiencies. These recommendations are listed below:
Note: This is not a requirement. A few sanitary survey reports for surface water, surface water purchased and ground water under direct influence systems (2 of 28 reviewed) were provided to the system more than 30 days after the sanitary survey. However, all were provided within 60 days of the survey. The EPA does acknowledge that the 30-day
goal that the UDEQ endeavors to meet for non-ground water systems is very challenging,
especially for larger systems, and the UDEQ is commended for providing the majority of sanitary survey reports to non-ground water systems in 30 days or less.
Of the 32 sanitary surveys reviewed as part of this evaluation where the survey resulted
in the finding of at least one significant deficiency, most significant deficiencies were
addressed with timely corrective actions. UDEQ noted that 8 of the 32 surveys had violations that were corrected late (passed 120-days) but before a violation was issued. EPA did not have documentation of the average days passed 120 that the deficiencies were still unaddressed but encourages UDEQ to issue violations promptly where either
the 120-days have passed, or CAP deadlines were not met. The EPA does acknowledge
there is often a large number of significant deficiencies to track and follow up on, and all violations were returned to compliance prior to the beginning of this review effort. The EPA also identified several best practices, some of them models for other States. These are
identified and are listed below:
The UDEQ is to be commended for providing reports to the water systems very promptly following sanitary surveys. UDEQ did not have a single report in the 50 reviewed for this effort take longer than 60 days to be reviewed and results communicated with the system.
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This fact includes sanitary surveys for some of the largest surface water systems in the state.
Sanitary survey reports were easy to read and understand and provided all essential information in a standard format. The reports clearly identify when the survey was conducted and who was present. The findings of the survey, including significant deficiencies, violations and recommendations, were clearly reported in both table format
and cover page for the report. Reports clearly identified when a written response is due
following the survey, and what steps the system should take if unable to correct the deficiency within 120-days.
From the EPA’s review of all available records, the UDEQ has very good communication
and compliance assistance with systems where significant deficiencies and violations
have been identified.
Violations identified during sanitary surveys require public notification. The UDEQ notifies systems in the cover letter of approved CAPs of the PN requirements if deadlines
within the CAP are not met.
The majority of sanitary surveys were conducted within 3-years and sanitary survey reports were sent to systems within 30 days of survey, with an average turn-around time of 16 days for all surveys reviewed regardless of water source. EPA commends UDEQ
for promptly communicating all sanitary survey results and therefore taking prompt
actions to address any significant deficiencies identified.
UDEQ also maintains a separate rating criteria system which is negatively impacted by unresolved significant deficiencies. The criteria assist in identifying and prioritizing
systems with numerous unresolved significant deficiencies which may not be caught by
the ETT due to grouping. In conclusion, the EPA appreciates the cooperative relationship with the UDEQ to conduct this assessment. The UDEQ manages a very effective sanitary survey program - conducting sanitary
surveys timely and issuing most sanitary survey reports within 30 days of conducting the survey.
The reports are well written, and it is clear to the system what significant deficiencies have been found, next steps, and corresponding deadlines. The UDEQ is also a model for other States regarding their clear and customizable sanitary survey template which takes into account every asset separately, allowing for fast turnaround and effective communication of sanitary survey
results. UDEQ also issues treatment technique violations when deficiencies are not addressed in
a timely manner, or a system exceeds the deadline in their CAP. Of the two treatment technique violations issued during the timeframe reviewed as part of this effort, both were returned to compliance before additional enforcement action was necessary. EPA commends UDEQ for its efforts in providing compliance assistance in a timely and effective manner to promptly correct
significant deficiencies.
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Appendix A Large Community Public Water Systems for this Review
PWSID PWS Name
PWS Type
Source Water Type Population Served Visit Date
UTAH06003 CLINTON CITY WATER SYSTEM CWS SWP 23000 9/22/2023, 8/11/2020
UTAH06015 BOUNTIFUL CITY WATER SYSTEM CWS SW 37500 8/17/2021, 9/18/2018
UTAH02004 BRIGHAM CITY WATER SYSTEM CWS GW 20540 8/29/2023, 9/17/2020
UTAH06019 NORTH SALT LAKE CITY WATER SYSTEM CWS SWP 18655 9/12/2022, 10/8/2019
UTAH06024 HILL AIR FORCE BASE CWS SWP 25470 8/29/2022, 9/24/2019
UTAH06043 LAGOON INVESTMENT COMPANY NTNC GW 15000 6/1/2023, 9/15/2020
UTAH11002 CEDAR CITY
WATERWORKS CWS GU 37760 6/21/2022,
8/7/2018
UTAH18006 WATERPRO INC CWS SW 28000 9/2/2022, 6/19/2019
UTAH18010 HOLLIDAY WATER COMPANY CWS SWP 15000 8/30/2022, 7/30/2019
UTAH18019 WHITE CITY WID CWS GW 15800 6/3/2021, 9/18/2018
UTAH18024 MURRAY CITY WATER SYSTEM CWS GW 38723 4/10/2023, 6/23/2020
UTAH18026 SALT LAKE CITY WATER SYSTEM CWS SW 360654 8/24/2023, 9/23/2020
UTAH18027 JORDAN VALLEY WCD CWS SW 82500 9/30/2021, 6/28/2018
UTAH18057 UNIVERSITY OF UTAH CWS GWP 57080 8/15/2023,
9/23/2020
UTAH18157 HERRIMAN CITY MUNICIPAL WATER DEPARTMENT CWS SWP 60000 7/18/2023, 7/17/2020
UTAH25003 SPANISH FORK CITY CWS GW 47169 6/22/2022, 5/16/2019
UTAH25006 PROVO CITY CWS SWP 116288 9/21/2023, 10/14/2020
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UTAH25016 LINDON CITY CWS GW 11072 7/6/2022, 4/30/2019
UTAH25022 PLEASANT GROVE CITY CWS GW 40000 8/24/2022, 10/1/2019
UTAH25138 SARATOGA SPRINGS CITY CWS SWP 58000 10/4/2023, 10/1/2020
UTAH26006 HEBER CITY WATER SYSTEM CWS GW 16276 8/31/2023, 10/20/2020
UTAH27008 IVINS CWS SWP 10265 10/5/2021, 11/2/2018
UTAH27021 WASHINGTON CITY CWS SW 38015 4/28/2022, 4/25/2019
UTAH29006 HOOPER WATER IMPROVEMENT DISTRICT CWS GW 19524 10/3/2022, 4/30/2019
UTAH29010 NORTH OGDEN CITY CWS GW 22000 7/28/2023, 7/30/2020