Pre-Survey Environmental Questionnaire
Please complete the questionnaire to the best of your knowledge. For questions that are not applicable, please respond with “N/A”. For questions that are unknown, please respond with “Unk”.
Property Information
Site Name/Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Assessor's Parcel Number(s)
Property Owner & Contact Information
Date Property Owner Purchased
-
Month
-
Day
Year
Key Site Manager & Contact Information
Property Description
Property Size
Number of Buildings
Size of Buildings
Date of Construction
-
Month
-
Day
Year
What is the Property currently being used for?
*
Please fill out the Current and Historic Tenant list at the end of this form.
Previous Investigations
Have any previous environmental investigations been performed at the property, including Phase I ESAs, Subsurface Investigations, Remediation, Asbestos or Lead-Based Paint surveys? (If yes, please provide copies)
Yes
No
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Neighboring Property Uses
North
South
East
West
Are you aware of any potential environmental concerns associated with the surrounding properties?
Yes
No
If you answered yes, please describe in the space below:
Property Features, Uses & Services
Stored Chemicals?
Yes
No
If you answered yes, please describe in the space below:
Underground or Aboveground Storage Tanks?
Yes
No
If you answered yes, please describe in the space below:
Spills or Releases of Chemicals?
Yes
No
If you answered yes, please describe in the space below:
Hazardous Waste Disposal?
Yes
No
If yes, please describe and list the disposal company information and contact number:
Dump Areas/Landfills?
Yes
No
If you answered yes, please describe in the space below:
Waste Treatment Systems?
Yes
No
If you answered yes, please describe in the space below:
Clarifiers/Separators?
Yes
No
If you answered yes, please describe in the space below:
Floor Drains or Sumps?
Yes
No
If you answered yes, please describe in the space below:
Stained Soil?
Yes
No
If you answered yes, please describe in the space below:
Hydraulic Lifts/Elevators
Yes
No
If you answered yes, please describe in the space below:
Dry Cleaning Operations
Yes
No
If you answered yes, please describe in the space below:
Oil/Gas/Water/Monitoring Wells
Yes
No
If you answered yes, please describe in the space below:
Environmental Permits or MSDS’s forms?
Yes
No
If you answered yes, please describe in the space below and send iformation available:
Current Tenants
Name of Business
Years Occupied
Type of Operation
Name of Business
Years Occupied
Type of Operation
Name of Business
Years Occupied
Type of Operation
Add additional tenants here if needed. Please include: NAME OF BUSINESS, YEARS OCCUPIED AND THE TYPE OF OPERATION
Historic Tenants
Name of Business
Years Occupied
Type of Operation
Name of Business
Years Occupied
Type of Operation
Name of Business
Years Occupied
Type of Operation
Add additional tenants here if needed. Please include: NAME OF BUSINESS, YEARS OCCUPIED AND THE TYPE OF OPERATION
Date Questionnaire Completed:
-
Month
-
Day
Year
Questionnaire Completed by:
Relation to Property:
Signature
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