Form B (CEHS-2) "Child Care Center - Indoor Environmental Health Assessment - Historical and Current Uses of Building and Site" - New Jersey

What Is Form B (CEHS-2)?

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 August 1, 2012;
  • 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 printable version of Form B (CEHS-2) by clicking the link below or browse more documents and templates provided by the New Jersey Department of Health.

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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:
CEHS-2
AUG 12
Page 1 of 2 Pages.
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:
CEHS-2
AUG 12
Page 1 of 2 Pages.
Child Care Center - Indoor Environmental Health Assessment
FORM B: HISTORICAL AND CURRENT USES OF BUILDING AND SITE
(Continued)
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:
CEHS-2
AUG 12
Page 2 of 2 Pages.
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