DDW-2025-003183

Utah Division of Drinking Water
IPS Deficiency Correction Notice
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Water System ID #UT AH Ofo'< 1
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
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D~ficiency Code
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How deficiency was corrected
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Date Corrected
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I certify that the information submitted with' • s report is true, and accurate. You may
electronically sign this form by typing your n~
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Print Name Signature Date
Corrections listed on attached IPS report ~ Supportive documentation attached K
DDW Approval ______________ _ Date I I ------

SS10 (WS001) Abatement
New rubber gasket on shoebox top

SS04 (WS001) Abatement
New screen on overflow discharge

V009 (ST002) Abatement
New rubber gasket was installed

V009 (ST003) Abatement
New gasket has been installed