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Environmental Issues Referral Form for Inspections of Day Care Centers and Group Day Care Homes

Name of Daycare Center ________________________________________________________________

Name of Inspector ____________________________________ Date of Inspection __________________

Address of Daycare Center ______________________________________________________________

Instructions: If item is observed, check applicable box. Space is provided at the end of the form for any additional information you think would be helpful. Taking a photograph or making a simple sketch can be helpful. You do not need to complete this form if no items are observed.

  1. Outdoor PropertyThe following items are visible at the property where the daycare center is located.___ Metal Drums or Barrels___ Old car/vehicle parts___ Discarded White Goods (i.e., old appliances)

    ___ Construction and Demolition debris pile (e.g., bricks/concrete, wood, plaster/drywall, plumbing fixtures, roofing, glass, electrical wiring, piping, asphalt pavement, insulation).

    ___ Barn(s), farm machinery/equipment

  1. Daycare Building(s)The following are visible at the building within which the daycare center operates.___ Loading dock, large delivery doors___ Old Mill Building/Mill Complex___ Old brick construction, resembles old factory building

    ___ Resembles funeral home

  1. Adjacent BusinessesThe following businesses are operating immediately adjacent to the child care center, and within the same building or building complex as the child care center. For example, if a child care center is located next door to a dry cleaner but the dry cleaner is in a separate building, do not check the box. If a daycare center is located within the same strip mall building complex as a nail salon/hair salon, but the nail salon is several (or more) doors away from the daycare center, do not check the box. However, if a child care center is next door to a nail salon/hair salon and within the same strip mall building, check the nail salon box.___ Dry Cleaner___ Nail Salon/Hair Salon___ Auto Repair/Auto Painting Shop

    ___ Copy/Print Shop

For Office Use Only
Referred to Inspector Date: ______________ Ref. by:_________________ Rec’d by:_________________
Inspector Follow-up Complete Date: _______________________________
Follow-up comments:
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