OPG 4.4 Sample-Environmental Restrictions Checklist

OMB No. 2502-0533
(Exp, xx/xx/xxxx)

Sample
Mark-to-Market
Environmental Restrictions Checklist
Project Name and Location (Street, City, County, ST,
Zip Code):

Form 4.4
Owner Name, Address (Street, City, ST, Zip Code),
and Phone:

Project Description:

ENVIRONMENTAL REVIEW FINDINGS
FLOOD PLAIN
Is the project located in a FEMA Special Flood Hazard Area? (Current flood plain maps
should be found in each HUD field office or call FEMA at 1-877-FEMA-MAP, FEMA’s web
site URL is www.fema.gov/FHM/)
Identify Map Panel and Date
Does the project currently carry Flood Insurance?
Do any structures appear to be within or close to the floodplain? (If yes and if the project does
not currently carry flood insurance, flood insurance is required.)
HISTORIC PRESERVATION (If yes, identify relevant restrictions below.)
Is the property listed on the National Register of Historic Places?
Is the property located in a historic district listed on the National Register of Historic Places?
Is the property located in a historic district determined to be eligible for the National Register?
AIRPORT HAZARDS
Is the project located in the clear zone of an airport? (24 CFR Part 51 D. If yes, Notice is
required.)
HAZARDOUS OPERATIONS
Is there any evidence or indication of manufacturing operations utilizing or producing
hazardous substances (paints, solvents, acids, bases, flammable materials, compressed gases,
poisons, or other chemical materials) at or in close proximity to the site?
Is there any evidence or indication that past operations located on or in close proximity to the
property used hazardous substances or radiological materials that may have been released into
the environment?
EXPLOSIVE/FLAMMABLE OPERATIONS/STORAGE (24 CFR Part 51C)
Is there visual evidence or indicators of unobstructed or unshielded above ground storage
tanks (fuel oil, gasoline, propane etc.) or operations utilizing explosive/flammable material at
or in close proximity to the property?
FOR YES RESPONSES, SUMMARIZE RESTRICTIONS BELOW:

September 2004

Form 4.4, Page 1

YES

NO

MARK-TO-MARKET PROGRAM ENVIRONMENTAL RESTRICTIONS CHECKLIST
ENVIRONMENTAL REVIEW FINDINGS
TOXIC CHEMICALS AND RADIOACTIVE MATERIALS
Petroleum Storage
Is there any evidence or indication of the presence of commercial or residential heating
activities that suggest that underground storage tanks may be located on the property?
If yes, are any such tanks being used? If yes, indicate below whether the tank is registered,
when it was last tested for leaks, the results of that test, and whether there are any applicable
state or local laws that impose additional requirements beyond those required under federal
law.
Are there any out-of-service underground fuel storage tanks? If yes, indicate whether the tank
was closed out in accordance with applicable state, local and federal laws.
Is there any evidence or indication that any above ground storage tanks on the property are
leaking?
Polychorinated Biphenyls (PCB)
Is there any evidence or indication that electrical equipment, such as transformers, capacitors,
or hydraulic equipment (found in machinery and elevators, installed prior to July 1, 1884) are
present on the site?
If yes, is any such equipment (a) owned by anyone other than a public utility company; and (b)
not marked with a “PCB Free” sticker?
If yes, indicate below whether such equipment has been tested for PCBs, the results of those
tests, and (if no testing has been performed) the proposed testing approach. (Electrical
equipment need not be tested but will be assumed to have PCBs)
If PCBs are found in non-electrical equipment over 50ppm it must be replaced or retrofitted,
otherwise any equipment with PCBs or assumed to have PCBs require an O&M Plan.
Asbestos Containing Materials (ACM)
Is there any evidence or indication of ACM insulation or fire retardant materials such as boiler
or pipe wrap, ceiling spray, etc. within the buildings on the property? If yes, the property is
required to have an Operations and Maintenance Plan for asbestos containing materials.
Lead Based Paint
Are there residential structures on the property that were built prior to 1978?
If yes, has the property been certified as lead-free?
If property has not been certified as lead-free, has a Risk Assessment been completed?
If yes, has the owner developed a plan including Interim Controls to address the findings of the
Risk Assessment including Tenant notifications and an Operations and Maintenance plan?
If yes, has a qualified Risk Assessor reviewed the Owner’s plan and O&M plan for compliance
with 24 CFR 35?
EASEMENT AND USE RESTRICTIONS
Are there easements, deed restrictions or other use restrictions on this property? (e.g. oil and
gas well pumping, transformer boxes/units, navigation, microwave, rights of way (ROW), for
hi-voltage power transmission lines, interstate/intrastate gas and liquid petroleum
pipelines, etc.)
FOR YES RESPONSES, SUMMARIZE RESTRICTIONS BELOW:

YES

If you have questions, please call or E-mail the HUD Housing Environmental Clearance Officer,
Eric Axelrod at (202-708-1104 x 2275)

September 2004

Form 4.4, Page 2

NO

Public reporting burden for this collection of information is estimated to average 0.5 hour per
response, including the time for reviewing instructions, searching existing data sources,
gathering and maintaining the data needed, and completing and reviewing the collection of
information. This information is required to obtain benefits. The office of Multifamily Housing,
Office of Affordable Housing Preservation 451 7th Street SW, Room 6216 6230 Washington,
DC 20410. HUD may not collect this information, and you are not required to complete this
form, unless it displays a currently valid OMB control number. Title V of the Departments of
Veterans Affairs and Housing and Urban Development and Independent Agencies
Appropriations Act of 1988 (P.L.106 65, 111 Stat. 1384) authorizes the FHA Multifamily
Housing Mortgage and Housing Assistance Restructuring Program. HUD implemented a
statutory permanent program directed at FHA-insured multifamily projects that have projectbased Section 8contracts with above- market rents. The information collection is used to
determine criteria eligibility of FHA-insured multifamily properties for participation in the Mark
to Market program and the terms on which participation should occur. The purpose of the
program is to preserve low-income rental housing affordability while reducing the long-term
costs of Federal rental assistance. While no assurances of confidentiality are pledged to
respondents, HUD generally discloses this data only in response to a Freedom of Information
request.