Sodium Chloride Runoff Damage Report

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 Northeast District Department of Health at email@nddh.org or (860) 774-7350.

Name(Required)
Email(Required)
Address(Required)

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.

MM slash DD slash YYYY
MM slash DD slash YYYY

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

Attach Water Quality Test Results for Sodium and Chloride from A DPH Approved Laboratory (test results can be uploaded).
Drop files here or
Accepted file types: doc, docx, pdf, Max. file size: 16 MB, Max. files: 4.
    Click here to find a list of DPH approved water testing laboratories.