Form Cdph 8602 – Fill Out and Use This PDF

State of California—Health and Human Services Agency	California Department of Public Health
	Food and Drug Branch

RETAIL WATER FACILITY LICENSE APPLICATION

PLEASE COMPLETE THIS FORM FULLY—INCOMPLETE APPLICATIONS WILL BE RETURNED

See Page 2 for Instructions.

1.	Name of Firm			9.	Facility Operator (name and title)
2.	DBA (List additional DBAs on separate sheet if necessary.)			10.	Facility Telephone Number			11.	Facility FAX Number
					(	)			(	)
3.	Facility Address (number, street)			12.	24-Hour Emergency Telephone Number			13.	E-mail Address
					(	)
4.	Facility Address (continued)			14.	Correspondent (name and title)
5.	City	State	ZIP Code	15.	Correspondent Telephone Number			16.	Correspondent FAX Number
					(	)			(	)
6.	Mailing Address (if different or P.O. Box number)			17.	Country (if other than United States)
7.	Mailing Address (continued)			18.	Website (URL)
8.	City	State	ZIP Code	19.	Do you have a Water Vending Machine at your facility?					Yes	No
					If yes, is your machine:		Inside facility		Outside facility (accessible after hours)
20.	Type of Ownership

21.	Owner’s Name / Corporate Name (if applicable)	State of Incorporation
22.	Owners’ or Officers’ Names and Titles	Owners’ or Officers’ Names and Titles

23. Water Treatment Used

24. Water Products
A—Drinking	B—Distilled	J—Purified by Deionization		K—Purified by Reverse Osmosis	M—Other:_________________
25. Is Your Water Source Public Water?		Yes	No
If yes, Please Provide the Following:

ALL APPLICANTS:

In order to receive a license from this Department, you must submit a copy of the coliform test results (and also test results for total dissolved solids ((TDS)) for “Purified Water” only). These test results must come from a certified laboratory.

By signature, I declare under penalty of perjury that all information provided herein is true and correct.

PLEASE DO NOT WRITE BELOW THIS LINE

Retail Water Facility License Application Instructions

Please Type or Print Your Application.

New Applicant/Renewal Applicant: Place an (X) in the box next to New Applicant if your firm has not previously applied for a Retail Water Facility License at this location while under the current ownership. Place an (X) in the box next to Renewal Applicant if your firm has already obtained a Retail Water Facility License for this location and you are renewing that license. If this firm has changed location, ownership, or both, place an (X) in the box adjacent to the appropriate response.

1.Name of Firm: Enter the full name of business, corporation, company, or organization applying for licensure.

2.DBA: Enter any other name(s) your company is doing business as.

3.–5. Facility Address: Enter the number, street, city, state, and ZIP code for this facility location.

6.–8. Mailing Address: Enter the full mailing address if different from the facility address.

9.Facility Operator: Enter the full name of the person who manages the operations at this facility and their title.

10.Facility Telephone Number: Enter the daytime business telephone number of this facility.

11.Facility FAX Number: Enter the facility FAX number.

12.24-Hour Emergency Telephone Number: Enter the telephone number to be called in the event of an emergency.

13.E-mail Address: Enter the facility e-mail address.

14.Correspondent: Enter the name of the person to contact for information regarding this application and their title.

15.Correspondent Telephone Number: Enter the daytime business telephone number of the contact person.

16.Correspondent FAX Number: Enter the daytime business FAX number of the contact person.

17.Country: Enter the country where your facility is located if outside of the United States.

18.Website: Enter the website address for your business if applicable.

19.Water Vending Machine: Place an (X) in the box indicating whether or not you have a water vending machine at your facility; Place an (X) in the box indicating whether your machine is located inside the facility or if it is accessible from outside the store.

20.Type of Ownership: Place an (X) in the box next to the appropriate legal description of the facility’s ownership.

21.Corporate Name: Enter the corporate name if applicable. Enter the State of Incorporation if applicable.

22.Owners’ or Officers’ Names and Titles: List the business owners’ or officers’ names and titles.

23.Water Treatment Used: Place an (X) in the box adjacent to the type of water treatment(s) used in this facility.

24.Water Products: Place an (X) in the box adjacent to the water products this facility dispenses.

25.Public Water Source: Place an (X) in the box adjacent to the correct answer. If you answer yes, please provide the name of the water district, their address, city, state, ZIP code, and phone number.

26.Private Water Source: Place an (X) in the box adjacent to the correct answer. If you answer yes, please provide the CDPH Private Water Source Operator’s License Number.

27.Sign the application, enter date signed, and print your name and title.

**LICENSE FEES ARE NON-REFUNDABLE AND NON-TRANSFERABLE TO OTHER LOCATIONS OR ENTITIES

NOTE: Please be advised that retailers that have a water vending machine or a window mount water vending machine accessible from outside the store are required to hold a separate license for the water vending machine. Any machine located outside your store or accessible outside the store after hours is NOT included in your retail water facility license.

MAKE CHECKS PAYABLE TO:	CALIFORNIA DEPARTMENT OF PUBLIC HEALTH
MAIL APPLICATION AND CHECK TO:
Regular Mail: California Department of Public Health		Overnight Mail: California Department of Public Health
Food and Drug Branch - Cashier		Food and Drug Branch - Cashier
MS 7602		1500 Capitol Avenue, MS-7602
P.O. Box 997435		Sacramento, CA 95814
Sacramento, CA 95899-7435

Call the Food and Drug Branch at (916) 650-6500 if you have additional questions about this application.