DDW-2025-005086

Utah Division of Drinking Water
IPS Deficiency Correction Notice
Water System Name_________________________________________________
Water System ID #UTAH________
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 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_____/_____/_____
Print Form
18055
WS001 Gasket was replaced in October 2024 and again in May of 202505/09/25
Steve McIntosh 5/31/25Steve McIntosh
Mt. Haven HOA
Submit by Email
SS10