Bottled Water Waiver Request
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
Included is a detailed explanation of the reason(s) checked above.
___________________________________ ___________________________
Signing Authority Date