DDW-2024-014836

Utah Division of Drinking Water
IPS Deficiency Correction Notice
Water System Name_________________________________________________
Water System ID #UTAH________

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_____/_____/_____
18113
WS001 Installed new locking well casing cap
and recessed wires with silicone seal
12/03/2024
Larry Hall 12/03/2024Larry Hall
Ruth's Diner
S013