Sodium Chloride Runoff Damage Report Form

Important: All fields are required and must be completed to guarantee the report will be reviewed.

If you have any questions about this form, contact Eastern Highlands Health District at EHHD@EHHD.ORG or 860-429-3325

Name

First NameLast Name

Phone Number Primary

Please enter a valid phone number.

Phone Number Alternate

Please enter a valid phone number.

Email

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Damaged Item(s) (e.g., water heater, piping, dish washer, clothes washer, well casing):

Description of Damage:

Date of Purchase of Damaged items:

Purchase Price of Damaged Items:

File Upload

Attach Water Quality Test Results for Sodium and Chloride from A DPH Approved Laboratory (test results can be uploaded). You can find a list of DPH approved water testing laboratories here:
https://portal.ct.gov/dph/Environmental-Health/Environmental-LaboratoryCertification/Environmental-Laboratory-Certification