DDW-2024-013953

Please complete this form and provide to the Division of Drinking Water within 24 hours of issuing public
notice.
CERTIFICATION OF PUBLIC NOTIFICATION
I _____________________________ certify that the attached public notice was issued from
(PWS Operator/Responsible Party)________________________ to _____________________________.
The notice attached was issued by (Date) __________________for the monitoring violation issued on
October 22, 2024.
(Describe method of delivery – by hand, mail, etc) __________________________________________
Signature __________________________________________ Date __________________________
Public Water System Name: ___________________________ PWS ID Number: ________________