Sodium Chloride Runoff Damage Report Form
If you have any questions about this form, contact the Farmington Valley Health District at info@fvhd.org or 860-352-2333
Important: All fields are required and must be completed to guarantee the report will be reviewed.
Full Name
First Name
Last Name
Contact Number
Please enter a valid phone number.
Email Address
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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 is strongly recommended that you take a picture of the damage and preserve relevant documentation in case it is needed for future claims.
Description of Damage:
Date of Purchase of Damaged items:
Purchase Price of Damaged Items:
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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