City of Meriden -Sodium Chloride Runoff Damage Report Form - 2024

Pursuant to PA 23.21, Sec. 19, this electronic reporting form is for the owner of any home or well that is damaged as direct result of sodium chloride run-off to register the damage with the local health department. Annually, the local health department will submit any report received for the previous year to the Office of Policy and Management, who 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.

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

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* 1. Check the box next to each statement below.

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.

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* 2. What is your name (First, Last)

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* 3. What is your street address, town/city, and zip code?

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* 4. What is your primary phone number?

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* 5. What is your email address?

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* 6. Please list all 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.

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* 7. Provide a description of the damaged item(s):

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* 8. Please note the purchase price of damaged item(s). NOTE: It is highly suggested that you attach a receipt/invoice providing the date and purchase price of the damaged appliance/item in Q9 below.

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* 9. Upload a picture of the receipt/invoice of the damaged item(s).

File size limit is 16MB.

PDF, PNG, JPG, JPEG file types only.

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* 10. 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.

File size limit is 16MB.

PDF, PNG, JPG, JPEG file types only.

Choose File