Preparer Contact Information
Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone
*
Please enter a valid phone number.
I am the:
- Select -
Buyer / Borrower
Seller
Property Environmental Information
Property Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Is the property PRESENTLY used as as an industrial use facility; including as a manufacturing operation, gasoline station, motor repair facility, commercial printing facility, dry cleaners, junkyard or landfill, or as a waste treatment, storage, disposal, processing, or recycling facility?
Yes
No
Please Describe in Detail
Has the property EVER been used as as an industrial use facility; including as a manufacturing operation, gasoline station, motor repair facility, commercial printing facility, dry cleaners, junkyard or landfill, or as a waste treatment, storage, disposal, processing, or recycling facility?
Yes
No
Please Describe in Detail
Has any adjoining property currently or ever been used as as an industrial use facility; including as a manufacturing operation, gasoline station, motor repair facility, commercial printing facility, dry cleaners, junkyard or landfill, or as a waste treatment, storage, disposal, processing, or recycling facility?
Yes
No
Please Describe in Detail
Are there currently, or to the best of your knowledge, have there been previously, any damaged or discarded automotive or industrial batteries, or pesticides, paints, or other chemicals in individual containers of greater than five gallons in volume or fifty gallons in the aggregate, stored on or used at the property or at the facility?
Yes
No
Please Describe in Detail
Are there currently, or to the best of your knowledge has there been previously, any industrial drums (typically 55 gallon) or sacks of chemicals located on the property or at the facility?
Yes
No
Please Describe in Detail
Is there a transformer, capacitor or any hydraulic equipment?
Yes
No
Please Describe in Detail
Are there underground storage tanks (UST’s) currently on the subject property?
Yes
No
If yes, attach copies of the registrations, spill insurance certificate, recent tank and line tightness test result (within the last six months) and verification that UST’s meet all the current compliance requirements.
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Have UST’s ever been removed from the subject property or abandoned in place?
Yes
No
If yes, state the years removed and attach a copy of all removal documents and the “no further action” letter issued by the State Fire Marshal’s Office.
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Are there currently or have there been any fill pipes, vent pipes or access ways protruding from the ground on the subject property that would indicate the presence of a UST or former UST?
Yes
No
Please Describe in Detail
Are there above ground storage tanks (AST’s) without secondary containment on the subject property?
Yes
No
Please Describe in Detail
Is the subject property registered with the EPA regarding any permits or for hazardous waste generation, treatment, storage or disposal?
Yes
No
If yes, attach a copy of permit, registration, and/or disposal
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Has any hazardous waste including petroleum products currently or ever been disposed of on or off site?
Yes
No
Please Describe Waste(s) Disposed in Detail
If yes, attach a copy of the most recent waste manifest and the borrower’s Hazardous Waste I.D.#
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Are there present/past enforcement actions by a regulatory agency for the subject property?
Yes
No
Please Describe in Detail
Are there any existing environmental liens, lawsuits, administrative actions or environmental easements associated with the use of the subject property?
Yes
No
Please Describe in Detail
Are there now or have there ever been any pits, ponds, or lagoons located on the property in connection with waste treatment or waste disposal?
Yes
No
Please Describe in Detail
Are there any groundwater monitoring wells (or groundwater contamination) located on the subject property?
Yes
No
State how many and describe their purpose
Does the subject property discharge waste (or wastewater) to an on-site sewer, on-site septic system, ditch or other waterway?
Yes
No
State the nature of the discharge
Attach a copy of the discharge permit
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Are there any outstanding Fire and/or Health Department violations for the subject property?
Yes
No
Please Describe in Detail
Have any hazardous substances or petroleum products, unidentified waste materials, tires, automotive or industrial batteries, or other waste materials been dumped above ground, buried and/or burned on the property?
Yes
No
Please Describe in Detail
Has a Phase I Environmental Site Assessment (ESA) or Regulatory Compliance Audit ever been performed for the subject property?
Yes
No
If yes, attach a copy of the report(s)
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Is the subject property structure a multi-tenant (10+ units) residential dwelling, nursing home or day care center constructed prior to 1978?
Yes
No
Please Describe in Detail
Is there any Asbestos Containing Material (ACM) in the building materials of the subject structure?
Yes
No
Please Describe in Detail
Is there historical or archeological significance to the subject property?
Yes
No
Please Describe in Detail
If you were not able to attach any of the required reports, comment on when those would be submitted
Questions or Comments
Signature
*
I hereby declare that the statements made by me in this questionnaire are, to the best of my knowledge and belief, a true and complete representation of the physical conditions, and the present and former uses, of the property.
Save
Submit
Should be Empty: