Environmental Site Questionnaire

The information on this form will be used for the purposes of evaluating the property associated with a loan application and the need for any follow-on Environmental Phase I or Phase II audit.

Note: ONLY the buyer/borrower or seller is allowed to complete this form.

Preparer Contact Information

Name (required)
 
 
 
 
 

ONLY the buyer/borrower or seller is allowed to complete this form.

Property Address (required)
 

Property Environmental Information

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?
 
 
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?
 
 
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?
 
 
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?
 
 
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?
 
 
Is there a transformer, capacitor or any hydraulic equipment?
 
 
Are there underground storage tanks (UST’s) currently on the subject property?
 
or drag files here.
     
    Have UST’s ever been removed from the subject property or abandoned in place?
     
    or drag files here.
       
      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?
       
       
      Are there above ground storage tanks (AST’s) without secondary containment on the subject property?
       
       
      Is the subject property registered with the EPA regarding any permits or for hazardous waste generation, treatment, storage or disposal?
       
      or drag files here.
         
        Has any hazardous waste including petroleum products currently or ever been disposed of on or off site?
         
         
        or drag files here.
           
          Are there present/​past enforcement actions by a regulatory agency for the subject property?
           
           
          Are there any existing environmental liens, lawsuits, administrative actions or environmental easements associated with the use of the subject property?
           
           
          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?
           
           
          Are there any groundwater monitoring wells (or groundwater contamination) located on the subject property?
           
           
          Does the subject property discharge waste (or wastewater) to an on-site sewer, on-site septic system, ditch or other waterway?
           
           
          or drag files here.
             
            Are there any outstanding Fire and/​or Health Department violations for the subject property?
             
             
            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?
             
             
            Has a Phase I Environmental Site Assessment (ESA) or Regulatory Compliance Audit ever been performed for the subject property?
             
            or drag files here.
               
              Is the subject property structure a multi-tenant (10+ units) residential dwelling, nursing home or day care center constructed prior to 1978?
               
               
              Is there any Asbestos Containing Material (ACM) in the building materials of the subject structure?
               
               
              Is there historical or archeological significance to the subject property?
               
               

               

               
               
               
               

              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.