DDW-2024-008015

Susceptibility Waiver Application for:

Name of Water System:
Name of Drinking Water Source(s)

I, ________________________________________________, Designated Person (per
R309-600) for the __________________________Water System, hereby state that I am
confident that a susceptibility waiver for VOCs and/or pesticides will not threaten public
health.

Signature:_______________________________________________
Date:_______________________________________________

Note: We must have a record of the monitoring results of at least one sample from the
VOC and/or pesticide parameter group taken in the last five years. A non-detect result is
required.

.