DDW-2024-006589

BACTERIOLOGICAL SAMPLE SITE PLAN
As part of the Revised Total Coliform Rule, the location from which samples are taken is to be varied. All water systems are
required to maintain a current bacteriological sample siting plan. The plan shows the locations of all sample sites from which
bacteriological tests are taken. Sample sites are to be representative of all pressure zones and each water source of the
distribution system. The sample plan should be revised regularly and following any major construction project impacting the
distribution system.
WATER SYSTEM INFORMATION
System Name: _______________________________________________ System #: UTAH___________
Street Address: ______________________________________________ Phone #: _________________
Mailing Address: ____________________________________________ Email: ___________________
Service Connections: ___________ Population Served: _________
SAMPLE COLLECTION
Samples collected by: __________________________________________________________________
Name of Laboratory: ____________________________________________________________________
Mailing Address: _______________________________________________________________________
State Lab Code: ______________ Phone #: ____________________ Fax #: ____________________
The Laboratory was sent a copy of this plan on: _______________________________________________
Utah Division of Drinking Water was sent a copy of this plan on:___________________________________
Seasonal Systems
MAP OF SYSTEM
Have you enclosed\attached a map of the distribution system showing the source (well, spring, etc.), storage tanks,
treatment facilities, distribution piping, routine sample locations, and follow-up (repeat) map? Yes No
PO Box 144830
Salt Lake City, UT 84114-4830
Phone: [phone]
Fax: [phone]
Email: [e-mail]
www.drinkingwater.utah.gov
Is the water operated seasonally? YES PARTIALLY NO
Dates of operation: Open:________________________ Close:______________________________________
Systems, which operate seasonally, are required to take an investigative sample prior to opening to the public. Where
will that sample be taken?
Location_______________________________________ Date sampled: _____________________________

SAMPLE LOCATIONS
The following describes each routine sample location, what months the location will be sampled, and where follow-up
(repeat) samples will be taken in the event of a “positive” routine sample.
Routine Sample Location: Follow-up (repeat) Sample Locations:
1. ____________________________________
(location name or address)
1. ______________________________________
(routine sample location name or address)
Description: ____________________________
(hose bib, sink faucet, etc.)

2. ______________________________________
(location name or address up-stream)
Water samples will be collected from this location during
the months of (circle):

3. ______________________________________
(location name or address down-stream)
1st Qtr: Jan. Feb. Mar.
4. ______________________________________ 2nd Qtr: Apr. May Jun.
3rd Qtr: Jul. Aug. Sep. (source)
4th Qtr: Oct. Nov. Dec.
Routine Sample Location: Follow-up (repeat) Sample Locations:
1. ____________________________________
(location name or address)
1. ______________________________________
(routine sample location name or address)
Description: ____________________________
(hose bib, sink faucet, etc.)

2. ______________________________________
(location name or address up-stream)
Water samples will be collected from this location during
the months of (circle):

3. ______________________________________
(location name or address down-stream)
1st Qtr: Jan. Feb. Mar.
4. ______________________________________ 2nd Qtr: Apr. May Jun.
3rd Qtr: Jul. Aug. Sep. (source)
4th Qtr: Oct. Nov. Dec.
Routine Sample Location: Follow-up (repeat) Sample Locations:
1. ____________________________________
(location name or address)
1. ______________________________________
(routine sample location name or address)
Description: ____________________________
(hose bib, sink faucet, etc.)

2. ______________________________________
(location name or address up-stream)
Water samples will be collected from this location during
the months of (circle):

3. ______________________________________
(location name or address down-stream)
1st Qtr: Jan. Feb. Mar.
4. ______________________________________ 2nd Qtr: Apr. May Jun.
3rd Qtr: Jul. Aug. Sep. (source)
4th Qtr: Oct. Nov. Dec.
Report Prepared by: ___________________________________________________________________

Signature and Title: ______________________________________________ Date: ______________

TP001 = Filtration
TP002 = Chlorination

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