New Jersey Department of Health

Consumer, Environmental and Occupational Health Service

Environmental and Occupational Health Assessment Program

PO Box 369, Trenton, NJ 08625-0369

Child Care Center - Indoor Environmental Health Assessment

Form B: Historical and Current Uses of Building and Site

Facility Name

Street Address

City

County

I. General Building Information
Owner Name

Owner Address

County

Year Built

Date(s) of Addition/Major Renovations

No. of Floors

No. of Rooms

Check all that are present in the building: Attic Basement Crawlspace
Give brief description of current usage of site and building (use additional sheet if necessary):

Give brief description of all prior uses of site and building (use additional sheet if necessary):

II. High Hazard Purposes – In Child Care or Educational Facility
Include diagram indicating areas where hazardous materials were stored/used.

Indicate (check all that apply) if building was ever used for any of the following:
None, go to next section.
Industrial Storage, describe:

Factory, describe:

Nail Salon, describe:

Dry Cleaning Facility, describe:

Gasoline Station, describe:

Other Contamination, specify:______________________________, describe:

III. High Hazard Purposes – In Adjacent or Proximate (Nearby) Buildings
1.	Include a site map which labels (by name) all nearby businesses.

2.	On a separate paper indicate the name, address and brief description of each business; include contact name and telephone number.

3.	Include a diagram indicating areas where hazardous materials were stored/used.

4.	Indicate (check all that apply) if it is an adjacent or proximate building and describe business.
None, go to next section.
Industrial Storage	Adjacent	Proximate
Describe:

Factory	Adjacent	Proximate
Describe:

Nail Salon	Adjacent	Proximate
Describe:

Dry Cleaning Facility	Adjacent	Proximate
Describe:

Gasoline Station	Adjacent	Proximate
Describe:

Other Contamination, specify:

Adjacent	Proximate
Describe:

IV. Industrial Site Recovery Act
Is this site under the jurisdiction of the Industrial Site Recovery Act?

No, go to the next section Yes, Complete the following:
Case Number

Case Manager

Case Manager Telephone No.

Provide Explanation:

Child Care Center - Indoor Environmental Health Assessment

Form B: Historical and Current Uses of Building and Site

(Continued)

CEHS-2

AUG 12	Page 2 of 2 Pages.

AUG 12	Page 1 of 2 Pages.

CEHS-2, Form B, Historical and current uses of Building and Site

CEHS-2, CEHS, child care center, indoor environmental health assessment, form b, historical and current uses of building and site

ewhite

2012-03-19

NJDOH