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Remediation Reporting Form

Form Number: NHDES-W-03-283 For assistance, please contact info@gettheleadoutnh.org or (603)506-6469

A combination of facility ID and outlet number. For example: 29875-3.
Round?
Please select the round you are reporting remediation for.
Please enter the sample result for the outlet you are reporting remediation for.
Method of Remediation
Select all that apply.
  • Fixture / outlet replacement
  • Permanently posted for no drinking / handwash only
  • Fixture turned off / removed
  • Plumbing corrections
  • Added filter
  • Filtered bottle fill station
Comments (if Applicable)
Please provide any additional information on remediation or re-testing
  • {name}
As of today, has corrective action been planned or completed?
File Upload (if Applicable)
For additional information or re-testing results report
Attach file
Drop files here

Do not submit passwords through this form. Report malicious form