Form CEHS-15 "Child Care Center Safe Building Interior Certification Renewal Application" - New Jersey

What Is Form CEHS-15?

This is a legal form that was released by the New Jersey Department of Health - a government authority operating within New Jersey. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on April 1, 2020;
  • The latest edition provided by the New Jersey Department of Health;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form CEHS-15 by clicking the link below or browse more documents and templates provided by the New Jersey Department of Health.

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Download Form CEHS-15 "Child Care Center Safe Building Interior Certification Renewal Application" - New Jersey

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New Jersey Department of Health
NJDOH USE ONLY
Tracking No.
Date Rec’d
Consumer, Environmental and Occupational Health Service
Environmental and Occupational Health Assessment Program
PO Box 369
Check
MO
No.:
Trenton, NJ 08625-0369
_________
Telephone: 609-826-4950
Fax: 609-826-4975
Email address:
Logged In by:
iep.program@doh.nj.gov
CHILD CARE CENTER
SAFE BUILDING INTERIOR CERTIFICATION RENEWAL APPLICATION
Directions: Please print clearly or type and fully complete form. When all items listed below are received, the review process will
begin. However, please allow 6-8 weeks for the check to clear. You MUST include:
• Fee: $450* certified check or money order made payable to “NJ Department of Health” or e-payment:
http://nj.gov/health/eohap/epayments.shtml. (NOTE: No personal or business checks or cash will be accepted.)
• Radon test results (<5 years old)
• Lead inspection report (for buildings built prior to 1979).
*Fee may vary. If it is determined that additional environmental testing is necessary for your center, you will be required to pay the
balance of the full $1,500 fee.
1. CHILD CARE CENTER INFORMATION
Are you a new owner / sponsor?
YES
NO
Has the center name changed since last certification?
YES
NO
Child Care Center Legal Name
DCF License Expiration Date
DCF License Number
Street Address
City
County
Contact Name
Title
Daytime Telephone
Mailing Address
Check if same as above
City
State
Zip Code
Operator Name
Check if same as Contact Name
Daytime Telephone
Building Owner Name
Check if same as Contact Name
Daytime Telephone
Childcare Center Contact / Operator Email Address
Payment Amount
Check / Money Order No.(s)
Check if online payment
$
2. INDOOR ENVIRONMENT CONDITIONS
Prior Uses
Co-Located
Year of Building Construction
Group B (Dry Cleaner or Nail/Hair Salon)
Yes
No
Group F (Factory/Industrial)
Dry Cleaner
Nail/Hair Salon
Group H (High Hazard)
Does your center have any current or previous indoor environmental conditions that
Group M (Gas Station)
required a NJDOH clearance letter?
Group S (Storage)
Yes
No
Other (includes funeral homes or other prior
If Yes, were you required to conduct remediation, additional sampling and/or
use that may have suspected contamination)
continued monitoring?
Describe:
Yes
No
If Yes Explain:
You must include the following:
Since your last renewal, has a dry cleaner
If yes, has indoor air monitoring been
or nail/hair salon moved into your building
conducted?
Radon report less than 5 years old
or structure?
Yes
No
If your building was built before 1978 you MUST
Yes
No
(Attach indoor air monitoring data.)
include the following:
Have there been changes to this location since last certification?
YES
NO
Current lead-based paint risk assessment
Is this an application to certify an expansion?
YES
NO
3. SIGNATURE
Operator/Contact Name (Please print legibly or type.)
Title
Signature
Date
CEHS-15
APRIL 20
New Jersey Department of Health
NJDOH USE ONLY
Tracking No.
Date Rec’d
Consumer, Environmental and Occupational Health Service
Environmental and Occupational Health Assessment Program
PO Box 369
Check
MO
No.:
Trenton, NJ 08625-0369
_________
Telephone: 609-826-4950
Fax: 609-826-4975
Email address:
Logged In by:
iep.program@doh.nj.gov
CHILD CARE CENTER
SAFE BUILDING INTERIOR CERTIFICATION RENEWAL APPLICATION
Directions: Please print clearly or type and fully complete form. When all items listed below are received, the review process will
begin. However, please allow 6-8 weeks for the check to clear. You MUST include:
• Fee: $450* certified check or money order made payable to “NJ Department of Health” or e-payment:
http://nj.gov/health/eohap/epayments.shtml. (NOTE: No personal or business checks or cash will be accepted.)
• Radon test results (<5 years old)
• Lead inspection report (for buildings built prior to 1979).
*Fee may vary. If it is determined that additional environmental testing is necessary for your center, you will be required to pay the
balance of the full $1,500 fee.
1. CHILD CARE CENTER INFORMATION
Are you a new owner / sponsor?
YES
NO
Has the center name changed since last certification?
YES
NO
Child Care Center Legal Name
DCF License Expiration Date
DCF License Number
Street Address
City
County
Contact Name
Title
Daytime Telephone
Mailing Address
Check if same as above
City
State
Zip Code
Operator Name
Check if same as Contact Name
Daytime Telephone
Building Owner Name
Check if same as Contact Name
Daytime Telephone
Childcare Center Contact / Operator Email Address
Payment Amount
Check / Money Order No.(s)
Check if online payment
$
2. INDOOR ENVIRONMENT CONDITIONS
Prior Uses
Co-Located
Year of Building Construction
Group B (Dry Cleaner or Nail/Hair Salon)
Yes
No
Group F (Factory/Industrial)
Dry Cleaner
Nail/Hair Salon
Group H (High Hazard)
Does your center have any current or previous indoor environmental conditions that
Group M (Gas Station)
required a NJDOH clearance letter?
Group S (Storage)
Yes
No
Other (includes funeral homes or other prior
If Yes, were you required to conduct remediation, additional sampling and/or
use that may have suspected contamination)
continued monitoring?
Describe:
Yes
No
If Yes Explain:
You must include the following:
Since your last renewal, has a dry cleaner
If yes, has indoor air monitoring been
or nail/hair salon moved into your building
conducted?
Radon report less than 5 years old
or structure?
Yes
No
If your building was built before 1978 you MUST
Yes
No
(Attach indoor air monitoring data.)
include the following:
Have there been changes to this location since last certification?
YES
NO
Current lead-based paint risk assessment
Is this an application to certify an expansion?
YES
NO
3. SIGNATURE
Operator/Contact Name (Please print legibly or type.)
Title
Signature
Date
CEHS-15
APRIL 20