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 G: SUMMARY OF TESTING AND EVALUATION RESULTS

Facility Name

Street Address

City

County

Directions:	Complete the following information for each sample taken. In addition, the following items must be attached for all samples listed:

1. Field sampling forms and analytical laboratory reports

2. Site drawings that identify sampling and testing locations

3. Sample chain of custody documents

If no samples were taken check this box:

I. Hazardous Substances that are Currently or were Formerly Present
Contaminant	Sample Result	Sample Number	Sample Date	Sample Type	Analytical Method	Sample Location

Child Care Center - Indoor Environmental Health Assessment

Form G: SUMMARY OF TESTING AND EVALUATION RESULTS

(Continued)

CEHS-7

AUG 12	Page 2 of 2 Pages.

AUG 12	Page 1 of 2 Pages.

CEHS-7, Form G: Summary of Testing and Evaluation Results

Form G, CEHS-7, Sampling, Summary of Testing and Evaluation Results, child care center, indoor environmental health assessment

ewhite

2012-03-20

NJDOH