DDW-2024-012277

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
23022
23022
23022
ST003/251
ST005/1342
TP001/Well 1
TP003/Well 3
TP004/Well 4
Distrubuted CCC Flyer to TEAD-N mail list
Emailed annual BFV inspection forms to Gary Rager
Heavy gauge and #14 screen are present see photo
Heavy gauge and #14 screen are present see photo
Provided ANSI/NSF 60 documentation for chlorine gas see attached
Provided ANSI/NSF 60 documentation for chlorine gas see attached
Label was added to bleach solution tank see attached
Oct 15, 2024
Oct 15, 2024
Sep 30, 2024
Sep 30, 2024
Oct 15, 2024
Oct 15, 2024
Sep 25, 2024
Jason Rawls Oct 15, 2024Jason Rawls
TOOELE ARMY DEPOT NORTH AREA (TEAD- N)
Submit by Email
M004
V007
V007
TD90
TD90
TG03
M007