Sodium Chloride Runoff Damage Report Form Logo
  • 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

  • Note:  If you need to remove a damaged item(s) it is strongly recommended that you take a picture of the damage and preserve relevant documentation in case it is needed for future claims.

     

  • NOTE:  It is highly suggested that you attach a receipt/invoice proving the date and purchase price of the damaged appliances/items.

     

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  • 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

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