MassDOT ES RES CERT 1 of 2
REV 1/2010
ENVIRONMENTAL SERVICES
RESIDENT’S CERTIFICATION FORM
FOR BOTTLED WATER REQUEST
Dear Sir/Madame:
The Massachusetts Department of Transportation (MassDOT), Highway Division is investigating
your complaint of salt contamination of your water supply. During our investigation, we may
provide bottled water to residents whose sodium intake is restricted to less than 2000
milligrams (two grams) per day because of documented health problems.
In order to qualify for bottled water, you must:
1. Be under a doctor’s care for a blood pressure or heart condition.
2. You must be on a 2000 milligrams per day, or less, sodium restricted diet.
3. You must already be purchasing diuretics and low sodium foods and can provide and
maintain receipts to document these purchases.
4. You must provide a statement from your physician documenting your restricted sodium
intake (see attached “Physicians Documentation Form”).
5. You must notify this office of any change in your condition that removes your need for
this bottled water.
6. You must certify your request for MassDOT supplied bottled water and have your
signature notarized by the Notary Public as follows:
I hereby certify that all the statements and information on and supplied by this request for
bottled water are true and complete to the best of my knowledge and belief, and that no
information necessary to the resolution of this complaint is withheld.
Resident’s signature:_______________________________________Date:__________________
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