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 E: water and sewer information

Facility Name

Street Address

City

County

Directions: Provide the following information. Use an additional sheet if necessary.

I. Potable Water Supply
Is the potable water certified to meet NJ DEP safe drinking water standards? Yes No
Check type of water supply:

On-site Well - Depth of well: _________________________ Depth of pump set at: ____________________

Public Community Water System

II. Waste System (Check one)
Septic System:	Size:	Location:
Describe Condition:

Cesspool:	Size:	Location:
Describe Condition:

Public Community Sewer System

III. Comments or Concerns
Indicate any comments or concerns regarding any of the above:

CEHS-5

AUG 12

CEHS-5, Form E: Water and Sewer

CEHS-5, Form E, water and sewer, indoor environmental health assessment, child care center, CEHS

ewhite

2012-03-19

NJDOH