New Jersey Department of Health

Consumer, Environmental and Occupational Health Service

PO Box 369

Trenton, NJ 08625-0369

Phone: 609-826-4935

RENEWAL APPLICATION TO OPERATE A

NON-ALCOHOLIC BEVERAGE AND/OR BOTTLING PLANT

PURSUANT TO N.J.S.A. 24:15.2	For State Use Only
Check/Money Order No.:
Check/MO Date:
Amount:
Logger Initials:
FOR THE PERIOD ENDING:	January 31,
LOCATED AT:
Failure to apply for renewal may subject you to penalty as provided by law. Expiration date appears on license. Please provide all information requested. If you have discontinued operations, complete last section only and return to above address. TYPE OR PRINT WITH BALL POINT PEN.
If Name or Address is incorrect, make necessary corrections below.
REASONS FOR CORRECTIONS:

Change in Trade Name

Change in Corporate Structure

Change in Location

Change in Mailing Address

Change in Ownership
Phone Number:
Fax Number:
Email Address:
Federal ID #/SSN:
MAKE CHECK OR MONEY ORDER PAYABLE TO: “TREASURER, STATE OF NEW JERSEY.”
BOTTLING PLANT FEE	$50.00
CORPORATE OFFICER INFORMATION
Name of President (Print)

Name of Secretary (Print)

Name of Vice-President (Print)

Name of Treasurer (Print)

AFFIDAVIT
State of ____________________________

County of ___________________________

I, ____________________________________________, being duly sworn according to law upon his(her) oath deposes and says that he(she) is (President, Vice President, Secretary, Treasurer, Owner) and hereby certifies that the information given in this application is true and complete to the best of his(her) knowledge, information and belief.

Sworn and Subscribed before me this ____________ day	___________________________________________

Signature and Title of Applicant

of _______________________, in the year ___________.

______________________________________________	_______________________________

Notary Public Signature	Date
DISCONTINUANCE OF OPERATIONS INFORMATION
Date Operations Discontinued

Name of Purchaser

Date Sold

Address of Purchaser

Signature of Former Operator

Address of Former Operator

F-39

JAN 13

F-

F-39, renewal application for certification to sell bottled water or bulk water

Elaine White

2013-01-28

ewhite

NJDOH