Environmental Health

• Name of Firm: The legal business name of the establishment as it will appear on the certificate.
• DBA: Doing Business As or Trade Name used to conduct business under a name other than the legal business name. This field is optional.
• Facility Location Address: The physical location where bottled water activities take place daily. Enter the full, exact address.
  • Facility addresses located outside the United States must be formatted according to the resident country's address format. Failure to correctly clarify the address number, street, province, and country will result in a deficiency of application.
• Facility Address (continued): Optional field for additional facility address information.
• Mailing Address: The address used to receive postal mail within the United States. Entering a foreign address here may prevent delivery of official Department correspondence.
• Mailing Address (continued): Optional field for additional mailing address information.
• Federal ID#: The IRS-issued federal identification number that belongs to the applicant establishment.
• Interstate Commerce
  
  • Product Shipped: The facility ships product across state lines.
  • Product or Raw Materials Received: Product or raw materials are received from outside the facility's resident state.
  • N/A: There is no interstate commerce.
• Type of Ownership: Indicate the type of ownership of the facility.
• Owners' or Officers' names and Titles: Enter the full name and title of each owner or each responsible officer of the owner business.

• Name: Name of the person responsible for daily operations of the applicant bulk or bottled water establishment. This individual must be knowledgeable about all functions pertaining to the processing establishment during business hours. This person is the primary contact for Department correspondence and inspections.
• Phone Number/Email: Enter the direct, year-round phone number and email address for the named Authorized Representative.
• Address: Confirm the mailing address where the Authorized Representative may receive mailed documents.

Check all types of bottled water that are produced or handled at the applicant facility.

Check all treatment methods conducted at the applicant facility.

Complete this section if you are applying as a Bottler facility.

For each brand name produced at the applicant facility, include the applicable product type (as indicated in the Bottled Water Products section) and the available container sizes. Attach a separate document if needed.

List all wholesale food distribution companies located within New Jersey that distribute product produced at the applicant facility. If available, provide each company's New Jersey Wholesale Food-Cosmetic license number. Attach a separate document if needed.

Name each source that supplies water to the applicant facility.

For each source:

• Enter the Source Type Code:
  1. Well
  2. Spring
  3. Public Community water System
  4. Other
• Indicate the full legal name of the owner of the source.
• Enter the full physical address of the source, correct according to the resident country's address format. Where no address exists, enter coordinates in latitude, longitude.

The application fee is based on the count of all named sources in the Water Source Information section. The fee pays for the processing and careful review of all submitted documentation, including all required source-water analysis for each application form. Applications submitted with insufficient payment will result in a deficiency of application.

Renewal Applicants – $650/source
New and all other applicants – $1000/source

Submit payment online using a check or credit card.

After successful online payment, you will receive an email receipt. Include a copy of your payment receipt with your application.

Foreign applicants: If the payer is not within the United States, enter any US address on the first screen and continue. The contact information on page 1 of the submission process does not reflect on the applicant or payment information and is only used in case of a problem with the payment transaction. You will be prompted for a billing address on a following screen.

Submit Online Payment

For each source named under Water Source Information, indicate YES or NO for each ground water influence column.

• Is the ground water source under direct influence? Check YES or NO according to the evaluated result.
• Evaluated for direct influence: Has the source been evaluated for direct influence of ground water? Check YES or NO.
• MPA Analysis: Has a Microscopic Particulate Analysis been conducted? Check YES or NO. If YES, and this is a new application or a new source for this applicant facility, provide a copy with the application.
• Other Approved Method: If there is no MPA Analysis, indicate whether an alternative approved method (such as a Hydrogeological Evaluation) was performed. If YES, and this is a new application or a new source for this applicant facility, provide a copy with the application.

• First two columns: check to confirm that each type of analysis was conducted and is included as a part of the report submitted with the application.
• Third column: indicate the analysis results for PFAS, PFOS, PFOA, AND PFNA.
• Description of water treatment processes: For each water treatment process listed at the top of page 2 of the application, write a description of the conducted process. Attach a separate document as needed.
• Inspection Agency: Indicate the name of the agency that most recently inspected the applicant facility.
• Date Last Inspected: Indicate the date of the most recent inspection.
• Label Review: Were product labels reviewed as a part of the most recent inspection? N/A for bulk water facilities.

For each Product Type as indicated on page 1 of the application, complete a Water Analysis form to reflect the analysis results of the most recent water analysis report conducted within six months prior to application.

Each laboratory analysis report must be accompanied by a Water Analysis form. Reports are not accepted without an accompanying Water Analysis form.

Each Water Analysis form must be accompanied by the original laboratory analysis report. Water Analysis forms are not accepted without original laboratory report documentation.

The application must be signed by the facility owner or operator. Third-party signatures are not accepted.