Environmental Risk Assessment Questionnaire #1
Name___________________________________________________________________
Street Address & Town____________________________________________________
Nature of your business____________________________________________________
1.
Are there, or were there ever, above-ground or underground storage tanks containing fuel,
chemicals, oil or any petroleum product on the property?
( )Yes
( )No
If yes, please complete attached Supplemental Tank Questionnaire.
2.
If petroleum products are stored above ground, is the storage capacity of any single container
more than 660 gallons, or is the aggregate storage greater than 1,320 gallons?
( )Yes
( )No
( ) Not applicable
If yes has a Spill Prevention Control and Countermeasure Plan been prepared?
( )Yes
( )No
If no, is the property serviced by a public water supply?
( )Yes
3.
Is there a well located on the property or any immediately adjacent property?
( )Yes
4.
( )No
( )No
Is there, or was there ever, a septic system or other type of on-site, private, waste treatment
system on the property?
( )Yes
( )No
If yes, please indicate its age, capacity, and whether or not it is still in
use:______________________________________________________________
If yes, has the system ever malfunctioned?
( )Yes
5a.
( )No
Please indicate if any activities on the property (whether past, present, or proposed, whether
conducted by you as owner or lessee of the real estate or by any other owner or lessee) ever included any
of the following: (check all that apply and provide details below):
( )Gas station
( )Auto, truck, bus or boat maintenance or
repair
( )Chemical Manufacturing
(
(
(
(
)Electronic component manufacturing
)Coal, gas or tar plant
)Pig farm
)Landfill (including waste disposal site)
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( )Business or farm storing or using
pesticides/herbicides
( )Furniture refinisher
( )Laboratory
( ) Car wash
( )Auto dealership
( )Auto body shop
( )Metal Plating
( )Dry cleaning
(
(
(
(
(
(
(
(
(
)Machine Shop
)Railroad Yard
)Print shop
)Electrical Substation
)Junkyard/ salvage yard
)Antique shop
)Dyeing or manufacturing facility
)Warehouse
)Textiles
_____________________________________________________________________
5b.
Is your business in these NAICS codes:
11000-114000; 236000-238000; 311000-339000;
221000, 441000, 444000, 447000, 454310, 484000, 493000, 811000, 812000 (See attached)
( )Yes
( )No
If yes please specify__________________________________________
5c.
Are there any of the following on the property:
1) Friable asbestos or asbestos containing material:
2) Urea formaldehyde foam insulation; or
3) Transformers or other equipment which contain dielectric fluid containing levels of
polychlorinated biphenyls (“PCBs”) in excess of State or Federal standards on or servicing
the property.
4) Lead based paint.
( ) Yes
( )No
If yes, please explain:_______________________________________
5d.
Does the property’s past, present or proposed use involve the generation, storage, handling, use
or transport of hazardous or toxic substances, materials or waste?
( )Yes
5e.
( )No
Are any petroleum products handled, stored, sold, or used on the property?
( )Yes
( )No
5f.
Does your business have any reporting requirements under the Emergency Planning and
Community Right to Know Act?
( )Yes
( )No
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5g.
Have you or your company ever been the subject of any action to enforce past or present
environmental violations?
( )Yes
( )No
IF ANY OF THE ABOVE QUESTIONS 5a through 5g APPLY, an ERAQ #2 MUST BE
COMPLETED.
6.
Will the proposed use of the property require any environmental or land use licenses, permits,
approvals, authorizations, certifications, notices or filings which are required by any governmental
agency for the operation of your business or the construction of any facilities or alterations of the
property. If issued or filed, please attach copies. (Use separate sheet if necessary):
_____________________________________________________________
______________________________________________________________
_______________________________________________________________
________________________________________________________________
7.
Is this property, or any other facility or property owned by you or any guarantor, now subject, or
has it ever been subject, to a proceeding to enforce any environmental or land use law, regulation or
ordinance or private lawsuit seeking damages or enforcement based on violation or any such law,
regulation or ordinance, or is one anticipated within the next 18 months?
( )Yes
( )No
If yes, please
explain___________________________________________________________________________
________________________________________________________________________________
The undersigned certifies that he/she/it has exercised due diligence and made all appropriate inquires in
completing this questionnaire and that the foregoing information is true and correct to the best of
his/her/its knowledge. In the event that additional environmental analyses are required as a condition of
its decision to lend, the undersigned authorizes the Lender or its agents to directly discuss the results of
these analyses with any consultants retained to perform them.
The undersigned acknowledges that this questionnaire is for lending risk assessment purposes only.
Should lend to the borrower after review of the questionnaire and any other evaluations it may require,
such lending decision should not be construed as determination or implicit representation that the
borrower’s real property or mode of operation is free of actual or potential environmental problems.
Dated:________________________
Signed:______________________________
Name: ______________________________
Title:________________________________
_____________________________________________________________________
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NORTH AMERICAN INDUSTRY CLASSIFICATION CODES
To be used on all commercial loans
This is a 6 digit field
Agriculture, Forestry, Fishing and Hunting
Agriculture, Production of Crops .................................................................. 111000
Agriculture, Production of Livestock ............................................................ 112000
Support Activities for Agriculture and Forestry ............................................ 115000
Forestry and Logging ..................................................................................... 113000
Fishing, Hunting, Trapping............................................................................ 114000
Mining – Codes Available Upon Request
Construction
Building, Construction, General Contractors and Operative Builders .......... 236000 Construction
Other than Building Construction/ General Contractors ............................... 237000
Construction-Special Trade Contract ............................................................ 238000
Manufacturing
Food and Kindred Products ........................................................................... 311000
Beverage and Tobacco Manufacturers .......................................................... 312000
Textile Mills................................................................................................... 313000
Textile Product Mills ..................................................................................... 314000
Apparel .......................................................................................................... 315000
Leather and Allied Product ............................................................................ 316000
Wood Product ................................................................................................ 321000
Paper Manufacturing ..................................................................................... 322000
Printing and Related Support Activities ........................................................ 323000
Petroleum and Coal Products......................................................................... 324000
Chemical Manufacturing ............................................................................... 325000
Nonmetallic Mineral Product ........................................................................ 327000
Fabricated Metal Product ............................................................................... 332000
Machinery Manufacturing ............................................................................. 333000
Electrical Equipment, Appliance and Component Manufacturing ................ 335000
Transportation Equipment Manufacturing .................................................... 336000
Furniture and Related Product Manufacturing .............................................. 337000
Miscellaneous Manufacturing ....................................................................... 339000
Electric, Gas & Sanitary Facilities................................................................. 221000
Automotive Dealers ....................................................................................... 441000
Buildings Materials ........................................................................................ 444000
Gas Service Station ........................................................................................ 447000
Other Fuel Dealers ......................................................................................... 454310
Trucking Transport ........................................................................................ 484000
Warehouse & Storage .................................................................................... 493000
Repair & Maintenance ................................................................................... 811000
Personal & Laundry Service .......................................................................... 812000
Exhibit 1
4
Schedule C
Supplemental Tank Questionnaire
To be completed whenever there is/are tank(s) on the property.
Attach to ERAQ #1 or ERAQ #2, as appropriate.
1. Name___________________________________________________
2. Do you presently own the storage tank (s) on the property?
( )Yes
( )No
If not, present owner’s name and address:______________________________
If yes, in whose names are the tanks registered with the Maine Department of
Protection?________________________________________
_____________________________________________________________
Environmental
3. Do you operate, or have you ever operated, the underground storage tank(s) on the property?
( )Yes
( )No
Present operator’s name and address:____________________________________
If no present operator, what is (are) the past operator(s)’ name(s) and address(es):
_____________________________________________________________________
_____________________________________________________________________
4. Please provide the following information applicable to any tank or tanks that exist, or have
existed on the property:
1
2
3
4
5
Tank Size:
Tank Use:
Product Stored:
In Service:
Located in
Sensitive
Geological Area:
Date Installed:
Date Removed:
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Exhibit 1
Schedule C
5. Are all of the storage tanks on the property registered with the DEP?
( )Yes
( )No
6. If so, what is/are the registration number(s): _____________________________
________________________________________________________________
(please provide a copy of the registration.)
7. Has any tank on the property been abandoned in place?
( )Yes
( )No
8. Is there, or has there ever been, any evidence of leaking or physical evidence of contamination?
( )Yes
( )No
Please describe:____________________________________________________
_____________________________________________________________________
9. Have tanks been pressure tested or otherwise inspected?
( )Yes
( )No
If yes, when and by whom? (Please provide a copy of all tests and inspections.)
_____________________________________________________________________
_____________________________________________________________________
10. Have reports been filed as required by DEP?
( )Yes
( )No
What reports are/were filed, and when? ________________________________
____________________________________________________________________
11. Are more than 42,000 gallons of petroleum products stored in underground tanks on the
property?
( )Yes
( )No
If so, has a Spill Prevention Control and Countermeasure Plan been prepared?
(Please provide a copy of the Spill Prevention and Countermeasure Plan.)
( )Yes
( )No
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12. Please make a sketch below of the approximate location of the tank(s) in relation to buildings,
property lines, and water supplies.
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