1.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.

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.

Do you Attest?

Yes

No

2.Name:

3.Address:

4.Phone Number:

5.Email Address:

6.Damaged Item(s): (Examples: water heater, piping, dishwasher, well casing, etc.)

7.Description of Damage:

8.Date of Purchase of Damaged Item:

9.Purchase Price of Damaged Item:

10.Email Water Quality Test Results for Sodium and Chloride from A DPH Approved Laboratory to Zach Faiella, Westbrook Director of Health.
Email: ZFaiella@WestbrookCT.us

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

I will email a water quality test report

I will not email a water quality test report