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Lead and Copper Certification Form
This is to certify that you provided the customers at your lead and copper sample sites of the results from their site.
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* Indicates required question
Water System Name
*
Your answer
Water System Number: UTAH_______
*
example: 01234 (include any leading zeros)
Your answer
Name of Owner or Operator
Your answer
Position/Title
Your answer
Today's Date
*
MM
/
DD
/
YYYY
What Type of Water System are You?
*
Community Water System
Non-Transient Non-Community System
If you're a NTNC System You Posted Notice At:
ex: Announcement Board, Each Individual Tap
Your answer
On
MM
/
DD
/
YYYY
Community Systems
Mailed/Delivered All Consumer Notices at all lead and copper sampling locations within 30 days of receiving results from the labratory?
Yes
No
Clear selection
Comments
If you checked No above, please give the date that you provided notice
Your answer
Email
Your answer
I Certify The Above Information is Correct
*
Type to sign name
Your answer
Submit
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This form was created inside of State of Utah.
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