DDW-2024-006638

uTAH DEPARTMENT
ENVIRONMENTAL 0
DR:NK:NGWATER
dttlbulon syslem
TY
P0 Box 144830
Salt Lake CitY, UT 84114-4830
Phone: (80'1)536-4100
Fax: [phone]
Email: [e-mail]
www.drin kin gwater.utah. gov
訃∬糊l褥 燃頸鼈群鱗鍮憾辮
sydem∴UTAH口 圏[4Dn
l\,lailing Address: F- O -
Samples collected bY:
Name of Laboratory:
'rti5itl t- ose L rax*" 435'152'l51D
The LaboratOγ WaS Sen a∞py dttS uan on ユノlノ l`
Utah Division o{ Drinking Water was sent a copy of this
Seasonal
ls the water operated seasonallY?I「l YES 沐o NO
Dates of operation: OPen:Closel
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:
MAP OF SYSTEM
@butionsystemShoWingthesource(we||,spring,etc'),StoragetankS,
treatment facilities, distribution piping, routine sample locations, and follow-up (repeat) map? [r] Yes [r] No
′フ
The following describes each routine sarnple location, what,months the location wi|| be sampled, and where fo|low.up
(repeat) sam-ples will be taken in the event of a"positive' routine sample'
2 310 rJ 3qp N)
(locaton name or address up_stream)
Water samples will be collected from this location during
the months of (circle):
(routne sample location name or
DescnpliOni
Water samples w∥be CO∥ecled from th s loCalon dunng
the monlhs of(cirCle〉
11
3__≦
≒撃 鼻 1114扇 1喜 誰 撃 祟 紛
Li二 ―
|:3J[__」Lさ L___」L14“型L』a)
lroutine sampte location flme or 9(tress;
(routine sample location name oraddress)
10SeЫ b gnk●ucel.elc→
Waler samples w∥l be co∥ecled iЮ m th s iOCalon dunng
(locaton narne or address up_stream)
the months of (c rcle)l
'1st Qtr: Jan.
(location name or address down_sheam)
3___:筆 ♀
gi甕 :}=扁 単 蔀摯 ギ
空 211
4____」塾 』」、三 尋 砕 響 =1-一
―一 一 ―
The following describes each routine sample location, what months the location will be sampled' and where follow-up
i"p.itl tr.pf.t *irl be taken in the event of a"positive' routine sample'
O樋
loc€lion name or address)G:oltntsample location name or address)
Water samples wilt be collected ftom this location during
the months of (circle):
Untr 9?
4_____輩 江 重」生
面 ♀寺
≦」越 十 一 ―一 ―
rc αヒ●。た
(hose bib, sink faucet, etc)aocatron name or addless up_slream)
Water samples will be collected from this location during
the months of (circle):
/Wl難 翌Descriotion: >tr\L-
(hose bib srnk laucet etc')(location name or
lhOSebb.Snk lau∝t elc)
Waler samples w∥l be conecled lrom th s loCaJon dunng
the months of(cirCle〉
ma政 んL尭 ″ι″1レ ヶ上∥ι与サ
いしr
0o N"
0。CaOm name or address downstream)
4___旦 三二生=三 ン遂禦祟卜
_一 一――――
(rout,re sample location na
(locaton name or address up_sfeam)
Report Prepared by:
Signature and Title:
e {6s tooJ
(ocalion name or address dovvn_stream)