Consumer Confidence Report (CCR) Certificate of] Delivery Form ** Submit this certification form and a copy of the delivered CCR no later than June: 30** gecomplancecomiogn (preferred); Fax: (303)758-1398 4300 Cherry Creek Drive South; Denver, CO 80246-1530 Step I- Public Water System Information  WQCD -Drinking Water CAS  PWSID: oolpgookSstem! Name:  Toun Of CheycnyeWels  Contact Person: Comments:  Debah G Knuosen  Phone #:  719.767.5B5  The water system named abovel hereby confirms that its consumer confidence report! has been distributedi to customers (or appropriate notices of availability have been given). Further, the system certifies thei information containedi int the reporti is correct and consistent with the compliance Gban 3 Kdu Deran G-Knudsen aonteacamiatak. 5laal3  monitoring dataj previously submitted to the Coloradol Department of Public! Health and Environment.  *System Authorized Signature  Printed Name  Title  Date  *Signature not required ifsubmitted through gedcomplamecomlegin. Date all CCR delivery methods AND good faith efforts were completed: A CCR report must be delivered to each customer unless the system complies with the requirements ofa waiver. Waivers (option 2 and 31 below) cannot be used to meet Tier 3 public notice delver-renuirements Please select which option was completed (onlys select one). Da Option 1: Direct delivery ofCCR to customers using the methods below: D Option 2 Waiver for systems serving: < 500 people  Step II- Consumer Confidence Report Delivery  5l3ila3 Rolshed  Direct hard copy delivery (mail or door-to-door) orl Directe electronic delivery (must meet] Department approved guidance). System must serve 500 or less and have completed BOTH oft the following 2 requirements. This cannot be used to satisfy Tier 3 1.7 Notified customers the CCR is available uponi request. This notice may be delivered either by mail, door-to-door delivery, or by posting System must serve less than 10,000 and have completed the ALL of the. following 31 requirements, This cannot be used to satisfy 2. Notified customers the CCR willr not be mailed. This notice may be delivered inar newspaper, on a billing statement, or other direct  public notice requirements., in an appropriate location.  2.The CCR isa available to the public upon request. A Option 3-1 Waiver for systems serving 6 10,000 people Tier 3 public notice requirements." 1.E Published full CCR in one or more local newspapers 3.7 The CCR is available1 tot thej public uponi request.  List] Newspaper(s):  Kvbwoa Press  Step II - Good Faith Efforts  ATLEASTONE "Good Faith" Effort must be completed. Please select which were completed. Posted: CCR on website required fors systems serving greater than 100,000 people List Website Link: Mailed CCR to postal patrons (list zip çodes in additional information: section below) List Zip Codes:  Advertised the availability oft the CCR in the news media Published: the CCR in local newspaper X Posted the CCR inj public plaçes apartments, businesses, etc)  List Media: List Newspaper: List Places: List Places: List Places:  Delivered multiple CCR copies to single bill addressès serving multiple persons (e.g  Delivered CCR to community organizations  Step IV- Violations and Exceedances  List any violations and/or fluoride: secondary MCL exceedance that you: are using the CCR to notify customers of below. Note: If using the CCR to meet public notification requirements, a description of the violation(s) must be provided in the CCR including all 10 required elements for a public notice, Visit ttps:/wgedcomplance.com/pn for  public notice instructions.                    22  2  0 0 11 i 00  e 80  0o    09 CI d0 4  00 00 00 0  2 2 4  3 2  s  3    2