Bottled Water Waiver Request

Date:

To: County Manager’s Office

From:

Department:

Facility:

Number of Employees:

This waiver is necessary for the following reason(s):

☐ No access to municipal water source

☐ Municipal water source was tested and does not meet the standards for drinking

water in the judgment of the Director of Environmental Health

☐ Municipal water is available but it is not conveniently accessible to staff

☐ Emergency Storage

Quantity Stored:___________

Location of Emergency Water: ___________

☐ Legal and/or contractual consideration

☐ Other

Included is a detailed explanation of the reason(s) checked above.

☐ Approved

☐ Not Approved

___________________________________ ___________________________

Signing Authority Date