CEHS-15
APRIL 20
New Jersey Department of Health
Consumer, Environmental and Occupational Health Service
Environmental and Occupational Health Assessment Program
PO Box 369
Trenton, NJ 08625-0369
Telephone: 609-826-4950 Fax: 609-826-4975
Email address:
iep.program@doh.nj.gov
CHILD CARE CENTER
SAFE BUILDING INTERIOR CERTIFICATION RENEWAL APPLICATION
Check MO No.:
_________
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
Mailing Address Check if same as above
Operator Name Check if same as Contact Name
Building Owner Name Check if same as Contact Name
Childcare Center Contact / Operator Email Address
Check / Money Order No.(s)
Check if online payment
2. INDOOR ENVIRONMENT CONDITIONS
Group B (Dry Cleaner or Nail/Hair Salon)
Group F (Factory/Industrial)
Group H (High Hazard)
Group M (Gas Station)
Group S (Storage)
Other (includes funeral homes or other prior
use that may have suspected contamination)
Describe:
Yes No
Dry Cleaner Nail/Hair Salon
Year of Building Construction
Does your center have any current or previous indoor environmental conditions that
required a NJDOH clearance letter?
Yes No
If Yes, were you required to conduct remediation, additional sampling and/or
continued monitoring?
Yes No If Yes Explain:
You must include the following:
Radon report less than 5 years old
If your building was built before 1978 you MUST
include the following:
Current lead-based paint risk assessment
Since your last renewal, has a dry cleaner
or nail/hair salon moved into your building
or structure?
Yes No
If yes, has indoor air monitoring been
conducted?
Yes No
(Attach indoor air monitoring data.)
Have there been changes to this location since last certification? YES NO
Is this an application to certify an expansion? YES NO
Operator/Contact Name (Please print legibly or type.)
