Drinking Water and Groundwater Protection Division APPLICATION TO SELL BOTTLED DRINKING WATER IN VERMONT NOTE: An Imported Bottled Water System is defined as a Bottled Water System with water sources and bottling facility located outside of Vermont. 1. Type of Approval (check one:) New Amendment Renewal; if Renewal/Amendment, include WSID #___________ New Applications: All of the following items must be included in new applications for Approval to Sell Bottled Drinking Water in Vermont. 2. Bottling Facility Owner: Phone: Fax: Bottling Facility Name: Email: Mailing Address: Bottling Facility Physical Address: (if different) Phone: 3. Administrative Contact (if different than Fax: Email: Mailing Address: 4. Water Source Information: Source Name: Source Type: Treatment: Public Water System? [ ] Yes, [ ] No Surface Water Well If YES, name: Spring Other _____________ Source Address: b. Source Name: Treatment: Source Type: Public Water System? [ ] Yes, [ ] No Well Surface Water If YES, name: Other _____________ Spring Source Address: c. Source Name: Treatment: Source Type: Public Water System? [ ] Yes, [ ] No Well Surface If YES, name: Spring Other _____________ Source Address: d. Source Name: Source Type: Treatment Public Water System? [ ] Yes, [ ] No Well Surface Water If YES, name: Spring Other _____________ Source Address: Note: If are additional sources, please attach a separate page containing the above information for each source. 9/12/16
Drinking Water and Groundwater Protection Division APPLICATION TO SELL BOTTLED DRINKING WATER IN VERMONT NOTE: An Imported Bottled Water System is defined as a Bottled Water System with water sources and bottling facility located outside of Vermont. 1. Type of Approval (check one:) New Amendment Renewal; if Renewal/Amendment, include WSID #___________ New Applications: All of the following items must be included in new applications for Approval to Sell Bottled Drinking Water in Vermont. 2. Bottling Facility Owner: Bottling Facility Name: Phone: Fax: Email: Mailing Address: Bottling Facility Physical Address: (if different) 3. Administrative Contact (if different than Phone: Fax: Email: Mailing Address: 4. Water Source Information: Source Name: Public Water System? [ ] Yes, [ ] No If YES, name: Source Type: Well Surface Water Treatment: Spring Other _____________ Source Address: b. Source Name: Public Water System? [ ] Yes, [ ] No If YES, name: Source Type: Well Spring Surface Water Other _____________ Treatment: Source Address: c. Source Name: Public Water System? [ ] Yes, [ ] No If YES, name: Source Type: Well Spring Surface Other _____________ Treatment: Source Address: d. Source Name: Public Water System? [ ] Yes, [ ] No If YES, name: Source Type: Well Surface Water Spring Other _____________ Treatment Source Address: Note: If are additional sources, please attach a separate page containing the above information for each source. 9/12/16
importedbwapprovalapp.docx