Corps of Engineers Civil Works Questionnaires Generic Clearance

HAZARDOUS MATERIALS AND WASTE STORAGE SURVEY

(Personal Interview or Mail Survey)

OMB 0710-0001

Expires: 30 September 2012

The public report burden for this information collection is estimated to average 25 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this data collection, including suggestions for reducing this burden, to Department of Defense, Washington Headquarters Services, Executive Services Directorate, Information Management Division, and the Office of Information and Regulatory Affairs, Office of Management and Budget, Washington, D.C. 20503, Attn.: Desk Officer for U.S. Army Corps of Engineers. Respondents should be aware that notwithstanding any other provision of law, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Please DO NOT RETURN your completed form to either of these offices.

HAZARDOUS MATERIALS AND WASTE STORAGE SURVEY

Are there are currently, or have there been in the past, any of the following items on the property? If you answer YES to any of the questions, please describe the types of items, quantity, whether they are still on the property, and if so, their current location on the next page.	YES	NO	NOT KNOWN
1. Automotive or industrial batteries
2. Pesticides in individual containers greater than 5 gallons in volume
3. Paints in individual containers greater than 5 gallons in volume
4. Solvents in individual containers greater than 5 gallons in volume
5. Other chemicals in individual containers greater than 5 gallons in volume
6. Industrial chemicals in drums (typically 55 gallons) or sacks of chemicals
7. Registered or unregistered fuel or chemical storage tanks above or below ground If so, have they been removed? Yes_____ No_____
Are there currently, or have there been in the past, any of the following items disposed of, buried, injected, leached, discharged, detonated, or burned on the property? If you answer YES to any of the questions, please describe the types of items, quantity, whether they are still on the property, and if so, their current location on the next page.
8. Petroleum products
9. Medical or infectious waste
10. Tires
11. Automotive or industrial batteries.
12. Barrels or drums either empty or with materials in them
13. Hazardous substances or waste
14. Transformers, capacitors or any hydraulic equipment indicating presence of polychlorinated biphenols (PCBs)

HAZARDOUS MATERIALS AND WASTE STORAGE AND DISPOSAL

(Continued)

MATERIAL AMOUNT STILL ON PROPERTY? IF SO,

DESCRIBE CURRENT LOCATION

WATER AND WASTEWATER

1. Is the property served by a municipal water supply? If so, name the supplier: _______________________________________________________________
Please answer the following questions about water supply and wastewater disposal practices at the subject property. For each question that you answered YES, please provide the additional information requested on the following page. Attach maps of the feature location on or near the property.	YES	NO	NOT KNOWN
2. Is the property served by a private well or non-public water supply system?
3. Are there wells on the property which are no longer used to supply water?
4. Are there dry wells, sumps, or other man-made constructed devices on the property used to convey surface water runoff into the ground?
5. Does the property discharge wastewater into a public wastewater treatment facility? If so, name the facility:
6. Does the property currently, or in the past, discharge wastewater, other than stormwater, into an individual wastewater treatment system (septic system) located on or adjacent to the property?
7. Are there, or have there been, any pits, ponds, lagoons, sumps, or other structures on the property used to dispose of wastewater or chemical.
8. If there are wells on the property, have they been tested for contamination? If so, provide copies of the test results.
9. Have contaminants been identified in any well, used or unused, on the property, or water system that exceed guidelines applicable to the water system?
10. Has any well been designated as contaminated by any government environmental or health agency?
11. Is the property located within a 100-year floodplain?
12. Are there any streams, rivers, major stormwater courses, ditches, or water channels on or within 500 feet of the property?

WATER AND WASTEWATER

(Continued)

QUESTION: LOCATION

Describe the nature of the item checked YES in the Describe the location on or in

previous table. To the extent possible, describe what relation to the subject property

is known about the construction of any water supply

wells, dry wells, and/or wastewater disposal systems

OTHER ENVIRONMENTAL CONCERNS

Please answer the following questions. For each YES answer, please describe the environmental condition on the bottom of this page and attach maps of the feature location on or near the property.	YES	NO	NOT KNOWN
1. Has fill dirt been brought onto the property that originated from a contaminated site or that is of unknown origin?
2. Is there currently, or has there been previously, any stained soil on the property?
3. Has contaminated soil been removed from or remediated at the property
4. Have there been fires or explosions at the property which may have caused contamination?
5. Are there now, or in the past, any vent pipes, fill pipes, or access ways indicating a fill pipe protruding from the ground on the property or adjacent to any structure located on the property?
6. Are, or has there been, any flooding, drains, or walls located in the facility that are stained by substances other than water?
7. Are there any critical habitats for sensitive, threatened, or endangered plant and/or animal species located on or within 1,500 feet of the property?

Describe any environmental conditions which resulted in a yes answer to any of the above questions:

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