Lead and Copper Certification Form

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This is to certify that you provided the customers at your lead and copper sample sites of the results from their site.

Water System Name *

Water System Number: UTAH_______ *

example: 01234 (include any leading zeros)

Name of Owner or Operator

Position/Title

Today's Date *

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

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

Clear selection

Comments

If you checked No above, please give the date that you provided notice

I Certify The Above Information is Correct *

Type to sign name

Submit

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This form was created inside of State of Utah.

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