Sodium Chloride Runoff Damage Report Form
I hereby attest to my understanding that the filing of this report form indicates my consent for thereport to be transmitted to the State of Connecticut, Office of Policy and Management in accordance with Section 19 of Public Act 23-21 and that this report is for informational purposes only and in no way binds the State of Connecticut to provide financial remediation to the filer and that filing of this form does not guarantee nor should it be filed with the expectation of receipt of financial remediation from the State of Connecticut.
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I attest to the above
I hereby attest that to the fullest extent of my knowledge, the damage reported on this form is the direct result of sodium chloride runoff.
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I attest to the above
Name
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First Name
Last Name
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
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Please enter a valid phone number.
Email
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example@example.com
Damaged Item(s) (e.g., water heater, piping, dish washer, clothes washer, well casing) NOTE: If you need to remove a damaged item(s) it isstrongly recommended that you take a picture of the damage and preserverelevant documentation in case it is needed for future claims.
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Description of Damage:
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Date of Purchase of Damaged Item(s):
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Purchase Price of Damaged Item(s): NOTE: It is highly suggested that you attach a receipt/invoice proving the date and purchase price of the damaged item(s).
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Water Quality Test Results for Sodium and Chloride from a DPH Approved Laboratory: NOTE: You can find a list of DPH approved water testing laboratories here: https://portal.ct.gov/dph/Environmental-Health/Environmental-Laboratory-Certification/Environmental-Laboratory-Certification
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