Contact Information - Red asterisk denotes REQUIRED.

Your Name / Organization

Street Address or Location of Property

City, State, Zip Code

 Your Email Address

Question

1.

Is the property or any adjoining property currently being used for an industrial use?

2.

Has the property or any adjoining property been used for an industrial use in the past year?

3.

Is the property or any adjoining property  currently used as or in the process of: commercial printing dry cleaners gasoline station junkyard landfill motor repair facility photo processing lab recycling facility waste treatment waste disposal waste storage waste processing Other None

4.

Has the property or any adjoining property  ever been used as or in the process of: commercial printing dry cleaners gasoline station junkyard landfill motor repair facility photo processing lab recycling facility waste treatment waste disposal waste storage waste processing Other None

5.

Are there currently, or have there been previously, any of the following stored on or used at the property: automotive or industrial batteries,  pesticides,  paints, or other chemicals in individual containers of greater than five gallons in volume or fifty gallons in the aggregate?

6.

Are there currently, or have there been previously, any industrial drums (typically 55-gallon) or sacks of chemicals located on the project site or property?

7.

Has fill dirt been brought onto the property which originated from a contaminated site or which is of unknown origin?

8.

Are there currently, or have there been previously, any pits, ponds, or lagoons located on the property in connection with waste treatment or waste disposal?

9.

Is there currently, or has there been previously, any stained soil on the property?

10 .

Are there currently, or have there been previously, any registered or unregistered storage tanks (above or underground) located on the property?

11.

Are there currently, or have there been previously, any vent pipes, fill pipes, or access ways indicating a fill pipe protruding from the ground on the property or adjacent to any structure located on the property?

12.

Are there currently, or have there been previously, any flooring, drains, or walls located at the property that are stained by substances other than water or are emitting foul odors ?

13.

If the property is served by a private well or non-public water system, have contaminates been identified in the well or system that exceed guidelines applicable to the water system or has the well been designated as contaminated by any government, environment, or health agency?

14.

Are there any environmental liens or governmental notifications relating to past or current violations of environmental laws with respect to the property, or any facility located on the property?

15.

Have you been informed of the past or current existence of hazardous substances or petroleum products or environmental violations with respect to the property or any facility located on the property?

16.

Have there been any environmental site assessments of the property that indicate the presence of or further study of hazardous substances or petroleum products on, or contamination of the property?

17.

Are there any past, threatened, or pending lawsuits or administrative proceedings concerning a release or threatened release of any hazardous substance or petroleum products involving the property?

18.

Does the property discharge waste water on or adjacent to the property, other than storm water, or into a sanitary system?

19.

Is there a transformer, capacitor, or any hydraulic equipment for which there are any records indicating the presence of PCBs?

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