Sodium Chloride Runoff Damage Report Form

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

Sec. 22a-474c. Sodium chloride run-off. Home or well damage. Health district electronic reporting system. Reporting. Identification of state or federal financial resources. Criteria and procedures. Not later than January 1, 2023, each local health district shall establish an electronic reporting system for the owner of any home or well that is damaged as the direct result of sodium chloride run-off to register such damage with the local health department. Not later than January 1, 2024, and each year thereafter, each local health department shall submit any report received pursuant to this section during the previous calendar year to the Office of Policy and Management. The Secretary of the Office of Policy and Management may identify any available state or federal financial resources to assist such owners with the costs of remediation, mitigation or repair of such homes or wells and establish any criteria and procedures for the issuance of any such financial assistance to such owners.

State of CT Statement *

I hereby attest to my understanding that the filing of this report form indicates my consent for the report 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.

Attestation Statement *

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.

Name *

Street Address *

City/Town *

Zip Code *

Phone Number: Primary *

Phone Number: Alternate

Email Address *

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 Item *

Purchase Price of Damaged Item * $

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

Receipt or Invoice of Damaged Item

Files must be less than 5 MB.
Allowed file types: gif jpg jpeg png pdf docx.

(9) 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-Laboratory-Certification/Environmental-Laboratory-Certification
Files must be less than 5 MB.
Allowed file types: gif jpg jpeg png pdf docx.

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Sodium Chloride Runoff Damage Report Form