6) Concluding about potential
problems and recommending for further action.
Environmental
Due Diligence Screening Questionnaire |
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| I. Site Ownership and Location: |
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| I . Site Owner___________________________________ |
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II. Site Location
_________________________________ |
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| II. Current And/Or Prior Use
Of Site ("Property"): |
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| _______________________________________________________ |
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| III. Current And/Or Prior Use
Of Adjacent Properties: |
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| _______________________________________________________ |
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| IV. Campus Site Inspection
Date: |
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| _______________________________________________________ |
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| V. Persons Interviewed (Owner): |
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| _______________________________________________________ |
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| Questions: |
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| I . Is Property an Industrial
use? |
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| Y____ |
Explain__________________________ |
N___ |
Unknown___ |
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| 2. Has Property been an Industrial
use at any time in the past? |
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| Y____ |
Explain_________________+________ |
N___ |
Unknown___ |
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| 3 . Is or was Property used as a gas station,
auto repair shop, laboratory, dry cleaners, and fill/junkyard,
printing shop, or as a waste treatment/storage/disposal/recycling
facility? |
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| Y____ |
Explain__________________________ |
N___ |
Unknown___ |
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| 4. Is or was any adjacent property used for
any industrial use or a commercial use listed in #3 above? |
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| Y____ |
Explain__________________________ |
N___ |
Unknown___ |
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| 5. Are or were any chemicals, paints, petroleum
products or pesticides stored or used on the Property? |
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| Y____ |
Explain__________________________ |
N___ |
Unknown___ |
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| 6. Are or were any drums or other bulk chemicals
located on the Property? |
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| Y____ |
Explain__________________________ |
N___ |
Unknown___ |
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| 7. Has fill dirt been brought onto the Property? |
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| Y____ |
Explain_____________________________ |
N___ |
Unknown___ |
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| 8. Are or were any sumps, pits, ponds or lagoons
related to waste treatment located on the Property? |
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| Y____ |
Explain__________________________ |
N___ |
Unknown___ |
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| 9. Is or was any stained soil or pavement located
on the Property? |
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| Y____ |
Explain__________________________ |
N___ |
Unknown___ |
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| 10. Are or were any above or underground storage
tanks located on the Property? |
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| Y____ |
Explain__________________________ |
N___ |
Unknown___ |
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| 11. Are or were any vent pipes, fill pipes,
or unidentified cover plates or pipes located on the Property? |
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| Y____ |
Explain__________________________ |
N___ |
Unknown___ |
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| 12. Is or was any maintenance or shop/service
area located on the Property? |
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| Y____ |
Explain__________________________ |
N___ |
Unknown___ |
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| 13. Has there been any previous disclosure of
hazardous materials in any buildings located on the Property? |
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| Y____ |
Explain__________________________ |
N___ |
Unknown___ |
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| 14. Are there any visible signs of spillage,
staining, residues, or corrosion in any buildings located
on the Property? |
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| Y____ |
Explain__________________________ |
N___ |
Unknown___ |
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| 15. Are there any chemical or other noxious
odors on the Property? |
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| Y____ |
Explain__________________________ |
N___ |
Unknown___ |
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| 16. Are there any transformers or other heavy
electrical equipment or hydraulics on the Property that contain
PCBs? |
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| Y____ |
Explain__________________________ |
N___ |
Unknown___ |
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| 17. Are there any asbestos-containing materials
located in buildings on the Property? |
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| Y____ |
Explain__________________________ |
N___ |
Unknown___ |
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| 18. Is Property served by any wells or other
non-public water supply? |
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| Y____ |
Explain__________________________ |
N___ |
Unknown___ |
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| 19. Has Owner/Tenant been informed of past or
current existence of hazardous substances or petroleum products
or environmental violations on the Property or any facility
located on the Property? |
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| Y____ |
Explain__________________________ |
N___ |
Unknown___ |
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| 20. Does Owner/Tenant know of any reports or
records of any release of or contamination from hazardous
substances or petroleum products on the Property? |
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| Y____ |
Explain__________________________ |
N___ |
Unknown___ |
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| 21. Does Owner/Tenant know of any past or pending
regulatory agency actions proceedings regarding hazardous
substances on the Property? |
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| Y____ |
Explain__________________________ |
N___ |
Unknown___ |
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| 22. Does any facility on the Property have any
regulatory permits related to hazardous substances/wastes,
wastewater discharge, or air emissions? |
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| Y____ |
Explain__________________________ |
N___ |
Unknown___ |
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| 23. Have any hazardous substances or wastes
or petroleum products been dumped, burned, buried, or otherwise
disposed of on the Property? |
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| Y____ |
Explain__________________________ |
N___ |
Unknown___ |
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| 24. Does Owner/Tenant know of any radiation
use on the Property? |
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| Y____ |
Explain__________________________ |
N___ |
Unknown___ |
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| Please advise whether further action is required
by initialing and returning this page |
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| ___________________________________________________ |
| ___________________________________________________ |
| ___________________________________________________ |
| ___________________________________________________ |
| ___________________________________________________ |
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| Identification of person(s) completing this
questionnaire: |
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_________________________________ |
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_________________________________ |
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OEH&S: |
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Further action required:____________ |
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No further action required:____________ |
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