Environmental Questionnaire

ASTM Environmental Questionnaire
Name of person filling out this Questionnaire:
Site Name:
Property Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Association to Property:

OwnerOccupantLender
Name of current property owner:
How long has the current property owner owned the property:
Please answer the questions below to the best of your knowledge.
1) Is the property or any adjoining property currently used for industrial use?

YesNoUnknown
If you answered yes, please explain in the space below:
2) To the best of your knowledge, has the property or any adjoining property been used for an industrial use in the past?

YesNoUnknown
If you answered yes, please explain in the space below:
3) Is the property or any adjoining property used as a gasoline station, motor repair facility, commercial printing facility, dry cleaners, photo developing laboratory, junkyard orlandfill, or as a waste treatment, storage, disposal, processing, or recycling facility?

YesNoUnknown
If you answered yes, please explain in the space below:
4) To the best of your knowledge has the property or any adjoining property been used as a gasoline station, motor repair facility, commercial printing facility, dry cleaners, photo developing laboratory, junkyard or landfill, or as a waste treatment, storage, disposal, processing, or recycling facility?

YesNoUnknown
If you answered yes, please explain in the space below:
5) Are there currently, or to the best of your knowledge have there been previously, any damaged or discarded automobile or industrial batteries, or pesticides, paints, or other chemicals in individual containers of greater than 5 gal (19 L) in volume or 50 gal (190 L) in the aggregate, stored on or used at the property or at the facility?

YesNoUnknown
If you answered yes, please explain in the space below:
6) Are there currently, or to the best of your knowledge have there been previously, anyindustrial drums (typically 55 gal [208 L]) or sacks of chemicals located on the property orat the facility?

YesNoUnknown
If you answered yes, please explain in the space below:
7) Has fill dirt been brought onto the property that originated from a contaminated site or that is of an unknown origin?

YesNoUnknown
If you answered yes, please explain in the space below:
8) Are there currently, or to the best of your knowledge have there been previously, any pits, ponds, or lagoons located on the property in connection with waste treatment or waste disposal?

YesNoUnknown
If you answered yes, please explain in the space below:
9) Is there currently, or to the best of your knowledge have there been previously, an stained soil on the property?

YesNoUnknown
If you answered yes, please explain in the space below:
10) Are there currently, or to the best of your knowledge have there been previously, any registered or unregistered storage tanks (above or underground) located on the property?

YesNoUnknown
If you answered yes, please explain in the space below:
11) Are there currently, or to the best of your knowledge have there been previously, any vent pipes, fill pipes, or access ways indicating a fill pipe protruding from the ground on the property adjacent to any structure located on the property?

YesNoUnknown
If you answered yes, please explain in the space below:
12) Are there currently, or to the best of your knowledge have there been previously, any flooring, drains, or walls located within the facility that are stained by substances other than water or are emitting foul odors?

YesNoUnknown
If you answered yes, please explain in the space below:
13) If the property is served by a private well or non-public water system, have contaminants been identified in the well or system that exceed guidelines applicable to the water system or has the well been designated contaminated by any government environmental/health agency?

YesNoUnknown
If you answered yes, please explain in the space below:
14) Does the owner or occupant of the property have any knowledge of environmental liens or governmental notification relating to the past or recurrent violations of environmental laws with respect to the property or any facility located on the property?

YesNoUnknown
If you answered yes, please explain in the space below:
15) Has the owner or occupant of the property 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?

YesNoUnknown
If you answered yes, please explain in the space below:
16) Does the owner or occupant of the property have any knowledge of any environmental site assessment of the property or facility that indicated the presence of hazardous substances or petroleum products on, or contamination of, the property or recommended further assessment of the property?

YesNoUnknown
If you answered yes, please explain in the space below:
17) Does the owner or occupant of the property know of 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 by any owner or occupant of the property?

YesNoUnknown
If you answered yes, please explain in the space below:
18) Does the property discharge wastewater on or adjacent to the property other than storm water into a sanitary sewer system?

YesNoUnknown
If you answered yes, please explain in the space below:
19) To the best of your knowledge, have any hazardous substances or petroleum products, unidentified waste materials, tires, automotive or industrial batteries or any other waste materials been dumped above grade, buried and/or burned on the property?

YesNoUnknown
If you answered yes, please explain in the space below:
20) Is there a transformer, capacitor, or any hydraulic equipment for which there are any records indicating the presence of PCB's on the property?

YesNoUnknown
If you answered yes, please explain in the space below:
21) Has there ever been a Phase I Report or any other environmental study preformed at the property in the past?

YesNoUnknown
If you answered yes, please explain in the space below:
Please list the current and historic tenants of the property:
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
Questionnaire Completed by:
Title:
Firm:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Date

MonthDayYear
Signature

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