New Jersey Department of Health

Consumer, Environmental and Occupational Health Service

P. O. Box 369

Trenton, NJ 08625-0369

609-826-4935

RENEWAL APPLICATION FOR CERTIFICATION

TO SELL BOTTLED WATER OR BULK WATER	FOR STATE USE ONLY
Check/Money Order No.:
Check/MO Date:
Amount:
Logger Initials:
FOR THE PERIOD ENDING:	June 30,
BOTTLER BULK WATER FACILITY	Certificate

Number:
Mailing Address:

FEE
Renewal Filing Fee:	$650.00
Number of Sources:
The fee is based on each source of supply.
Location Address:

No. of Sources @ $650	=
Total Remitted:	$
In accordance with the provisions of N.J.A.C. 8:21-5.15, the undersigned hereby applies for a certification renewal to distribute and offer for sale in New Jersey, bottled or bulk water. Provide all information and mail the original application and your check with the appropriate fee to the above address. Type or print clearly with a ballpoint pen, sign and date the application.
CORRECTIONS: IF NAME OR ADDRESS IS INCORRECT, MAKE NECESSARY CORRECTIONS BELOW.
Phone Number
Change in Trade Name
Change in Location
Change in Mailing Address
Phone Number Change
Change in Ownership

DISCONTINUANCE OF OPERATIONS INFORMATION
Date Operations Discontinued

Name of Purchaser

Date Sold

Address of Purchaser

WATER SOURCE INFORMATION

(Source Type Codes: 1-Well 2-Spring 3-Public Community Water System 4-Other)
Name of Source	Source Type	Owner of Source	Location Address

Name of Inspecting Agency (for out-of-state bottlers)

Date of Last Inspection

DIRECT WATER INFLUENCE ON GROUND WATER SOURCES
Name of Source	Is Ground Water Source Under Direct Influence?

Yes	No	Evaluated for	MPA*	Other

Direct Influence	Analysis	Approved

Yes	No	Yes	No	Method
Please provide all the supporting data on MPA testing (*Microscopic Particulate Analysis - EPA 910/9-92-029) or other acceptable methodology for these determinations OR submit a letter from the approving source agency that a surface water influence determination has been conducted and the results.

BOTTLED WATER PRODUCT INFORMATION
Bottled Water Types:
Bottled Water	Artesian Well Water	Deionized Drinking Water
Drinking Water	Purified Water	Reverse Osmosis Drinking Water
Sterilized Water	Distilled Water	Well Water
Spring Water	Sparking Bottled Water	Ground Water
Artesian Water	Mineral Water	Other:
List the Names and Addresses of all New Jersey Certified Water Testing Laboratories used, including their N.J. Lab Certification No.:

Attach Additional Sheets, if Necessary
List the Brands, Trade Names, and Private Labels Distributed in New Jersey (submit product labels):

Attach Additional Sheets, if Necessary
List the Names and Addresses of Companies in New Jersey Used to Distribute Product:

Attach Additional Sheets, if Necessary

BOTTLED WATER TREATMENT INFORMATION
Bottled Water Treatments:
UV Irradiation	Distillation	Filtration (filter size):	Reverse Osmosis
Ozonation	Deionization	Sub-Micron Filtration:	GAC Filtration
Provide a complete description of the water treatment processes used and attach additional sheets as necessary. Submit water analysis for both source water and finished product for microbiological, inorganic, volatile, semi-volatile, synthetic organic, secondary standards, radiological and total trihalomethane results. Source water testing of community water supplies is not required. See the Bottled Water Quality Standards included for the application for specific testing parameters.

CERTIFICATION

I hereby certify that I will distribute and offer for sale only bottled water and/or bulk-water that conforms with the rules and regulations of the State of New Jersey as specified in N.J.A.C. 8:21-5, Subchapter 5.
Name of Applicant

Title

Signature	Date

RENEWAL APPLICATION FOR CERTIFICATION TO SELL BOTTLED OR BULK WATER

(Continued)

F-42

JAN 13	Page 2 of 2 Pages.

JAN 13	Page 1 of 2 Pages.

f-42, Renewal Application for Certification to Sell Bottled or Bulk Water

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2013-01-16

NJDOH