ENVIRONMENTAL QUESTIONNAIRE AND DISCLOSURE STATEMENT

To be completed by occupant or property owner:

The purpose of this questionnaire is to provide information about the past and present ownership and uses of the real property upon which lender will rely for security in deciding whether to extend credit. Please respond fully to all questions, including attaching supporting documentary evidence where appropriate. If unable to answer after diligent inquiry, respond "unknown" and explain why the information is unavailable. If space is inadequate to answer, please attach additional pages as needed. If applicant conducts business at multiple locations, a separate disclosure statement should be supplied for each location.

HISTORY OF PROPERTY

1. The present and previous owner(s)/occupant(s) (if different than owner), and the time period of which each owner or occupant of the property (start with present and include a twenty year history if possible):

A. ________________________________________________________

B. ________________________________________________________

C. ________________________________________________________

2. Date of last transfer of ownership: _________

A. Was a pre-acquisition site assessment or environmental survey preformed? __YES ___ NO If yes, include a copy of the report

3. Describe present and previous use(s) of the adjacent (bordering) properties (describe the location of the adjacent properties in the last column - e.g. property to the East or Northeast).

A. ________________________________________________________

B. ________________________________________________________

C. ________________________________________________________

4. Were any of the uses of adjacent properties a disposal facility, a dumpsite, storage for, or involving use of, chemicals, hazardous waste ofÊ toxic materials? ___YES ___ NO If yes, please identify and explain.

5. State the year in which buildings or improvements on the premises were constructed. ________ Do any building materials contain asbestos? ___YES ___NO

A. Have any asbestos tests or surveys been performed on the site? ___YES ___NO

B. If yes, attach test/survey reports. If not available, describe results.

6. Are there electrical transformers, switches, capacitors, or other comparable devices on or adjacent to the premises? ___YES ___NO If yes, have they been inspected for the presence of PCBs or hazardous toxic substances? ___YES ___NO

A. If yes, attach inspection reports. If report is not available, describe results.

B. Have there been any leaks, spills, or fires on site involving PCB electrical equipment? ___YES ___NO? If yes, please describe.

C. Have there been any leaks, spills, or fires on site involving PCB electrical equipment? ___YES___NO If yes, please describe.

7. Are there now or have there ever been, underground storage tanks located on the property or the properties adjacent to the site? ___YES ___NO

A. If yes, indicate the number of tanks, the contents and age or date of removal of each tank.

B. Have any of the following been provided for the underground tanks and their associated piping? (Please attach any supporting documents)

_________ integrity testing

_________ leak detection system

_________ secondary containment

_________ cathodic protection

_________ inventory reconciliation

_________ overfill spill protection

_________ other (please describe)

Please attach any supporting documents.

8. Are there any above or below ground pipelines on site now which are used to transfer chemicals? __YES __NO

A. If yes. Please describe.

B. Have the pipelines been inspected or tested for leaks? ___YES ___NO If yes, please indicate the results, and attach all supporting documents.

9. Are there chemicals, hazardous waste or toxic materials currently stored, or have they been stored, on site in the past? ___YES ___NO

A. If yes, check all applicable categories of storage methods:

_____ drums

_____ containers

_____ waste piles

_____ pits

_____ sumps

_____ aboveground tanks

_____ surface impoundment's/ponds/lagoons

10. Has there been, or is there now, any physical evidence of spills, leaks, or other releases of chemicals, hazardous wastes to toxic materials on the property or an adjacent property?___YES ___NO

A. If yes, please describe.

11. Are there any past, current or pending regulatory actions, lawsuits or administrative proceedings involving the present business or the subject property alleging noncompliance with environmental regulations or environmental damages? ___YES ___NO

A. If yes, please describe, and attach all relevant documents.

12. Has the subject property or any nearby property ever been listed, proposed, or investigated as a Federal or State Superfund site? ___YES ___NO

A. If yes, please describe, and attach all relevant documents.

I/We are familiar with real property described in this questionnaire. By signing below, I/We represent and warrant to the Greater Sacramento Certified Development Corporation that the answers to the above questions are complete and accurate to the best of my/our knowledge and that reasonable inquiry has been made to complete these answers. I/We also understand that Greater Sacramento Certified Development Corporation will rely on the completeness and accuracy of the answers in assessing any environmental risks associated with the property.

SELLER OR OCCUPANT:		GSCDC:
__________________________________		By:________________________________
Print Name		Raymond F. Sebastian, Executive Director
By:___________________ Date:______

PROPOSED USE OF PROPERTY

To be completed by buyer/applicant:

13. The proposed use(s) of the property:

14. Does your business use chemicals or substances which require permits or licenses to own, use, or remove from the property? ___YES ___NO

A. If yes, please attach copies, or describe the permits/licenses being sought.

B. Are any inspections required prior to the issuance or renewal of such licenses or permits?___YES ___NO

C. If yes, please attach copies of inspection report(s).

D. Are you presently in compliance with all regulation for continued utilization of such permits or licenses? ___YES ___NO

15. Are you planning to store any petroleum products or installing or maintaining any underground storage tanks on the subject site?__ YES ___NO

A. If yes, please describe, and attach all relevant documents.

I/We are familiar with the property/business described in Section II of this questionnaire. By signing below, I/we represent and warrant to Greater Sacramento Certified Development Corporation that answers to the above questions are complete and accurate to the best of my/our knowledge. I/we understand that Greater Sacramento Certified Development Corporation will rely on the completeness and accuracy of the information provided in assessing any environmental risks associated with the property. By signing below, I/we acknowledge that if I/we did not complete Section I above, I/we have received and read the information provided.

APPLICANT:
_________________________________________
Print Name
By:__________________________ Date:_______

Back to Top