ENVIRONMENTAL CONDITIONS STATEMENT
for the benefit of Farm Credit Services Southwest, FLCA, PCA (“FCSS”)
IDENTIFICATION:
Name of Owner:
STATEMENT OF SIGNER:
The information requested in this form is necessary to complete an application for a FCSS loan or loan servicing action. FCSS has
been advised that the individual signing this statement has the most knowledge about the following issues. Please answer all
applicable questions to the best of your knowledge. Where appropriate, attach copies of documents verifying regulatory compliance
and responding to yes answers or other requests for information. FCSS has the right to deny any application if information provided
is false, misleading, unacceptable, or incomplete.
Real Property Security:
Statement applies to the following described property:
Use Permit and Government Notices:
1.
Is there a use permit for pesticides? ( ) Yes
( ) No. If yes, Permit No. _________________.
2.
Have any notices been received from any governmental authority concerning the removal of any toxic or hazardous waste, material, or
substance from the property? ( ) Yes
( ) No. If yes, briefly describe which authority, when notice was received and the nature of the
notice:
3.
Is subject property on a national or state hazardous waste site priority list? ( ) Yes
numerical score or rating assigned:
( ) No. If yes, indicate which list(s) and any
Storage Tank(s):
Are there any underground or above ground storage tanks on the subject property? ( ) Yes
information (NOTE: If more than two tanks, use a separate page):
TANK NO. 1:
( ) Aboveground ( ) Underground
Is tank in use? ( ) Yes
Location:
What is/was tank used for?
What is the size of the tank?
Has tank leaked? ( ) Yes ( ) No
If yes, give details:
( ) No. If yes, for each tank provide the following
( ) No
What is its age?
Did you obtain permit (if applicable)? ( ) Yes ( ) No ( ) Unknown
Has tank been tested? ( ) Yes ( ) No If yes, indicate name of testing company and date tested
TANK NO. 2:
( ) Aboveground ( ) Underground
Is tank in use? ( ) Yes
Location:
What is/was tank used for?
What is the size of the tank?
Has tank leaked? ( ) Yes ( ) No
If yes, give details:
( ) No
What is its age?
Did you obtain permit (if applicable)? ( ) Yes ( ) No ( ) Unknown
Has tank been tested? ( ) Yes ( ) No If yes, indicate name of testing company and date tested
Collection Sites:
Are there any open pits or dumps? ( ) Yes ( ) No; drain water evaporation ponds? ( ) Yes ( ) No; or holding ponds with chemical wastes or
effluents? ( ) Yes ( ) No If yes, for each pit/pond provide the following information (NOTE: if more than one pit/pond, use a separate page):
FCS 1279 (10-06) Environmental Conditions Statement (Page 1 of 2)
PIT/POND NO. 1: Dimensions (or size):
Is pit/pond permitted? ( ) Yes (Complete Section A)
Age:
( ) No (Complete Section B)
( ) Unknown
Section A:
If permitted, specify type of permit and attach copy:
( ) Department of Health Services ( ) SWQCB ( ) Other:
Is permit current? ( ) Yes ( ) No. If no, state why and answer questions in Section B:
Section B:
If not permitted or permit is not current, provide the following information:
Substances in pit/pond
Soil type
Location of nearest well, drainage ditch, or stream that may be contaminated by percolation or overflow
Has pit/pond been tested for hazardous materials? ( ) Yes ( ) No; for concentration levels? ( ) Yes ( ) No.
If hazardous materials have been identified, list and provide information on concentrations above acceptable levels on separate sheet.
Drums/Containers:
Are pesticides or other hazardous substances stored on the security?
( ) Yes
( ) No. If yes, continue:
1.
Briefly describe where they are located (e.g., in a shed 150 feet SE of the farm residence)
2.
Is there an inventory of contents? ( ) Yes
substances stored:
3.
Are any hazardous substances disposed on the property? ( ) Yes
( ) No. If yes, attach a copy. If no, briefly describe types of pesticides or other hazardous
( ) No. If yes, specify where and how the substances are disposed of :
Miscellaneous:
1.
Is the undersigned aware of contamination or threat of contamination from adjacent or nearby properties, (e.g., subject property is located
next to a dumpsite or an industrial plant with chemical holding ponds)? ( ) Yes ( ) No. If yes, briefly describe evidence:
2.
Is the undersigned aware of any hazardous waste or other environmental problems existing on the property (whether from this operation or
previous owners' operations) that has not already been described above? ( ) Yes ( ) No. If yes, briefly describe problem:
CERTIFICATION AND ACKNOWLEDGMENT
The undersigned hereby certifies that the foregoing is true and complete to the best of his/her knowledge and is given for the purpose of obtaining
credit from FCSS.
Date:
Signature:
Print name of signer:
For Appraiser Use Only
Does the information on this form adequately reflect conditions on the property? ( ) Yes
report.
FCS 1279 (10-06) Environmental Conditions Statement (Page 2 of 2)
( ) No. If no, refer to comments within the appraisal
Date
FCS 1279 (10-06) Environmental Conditions Statement (Page 3 of 2)
Appraiser