Site Visit Report

Site Inspection & Interview

Step 1: Basic Information

Property Address * Simple visual description of site and buildings on property * Inspection Date * Weather: Example - Sunny, 75°F * Inspector Name * Front Image of Subject Property * Additional Exterior Image of Subject Property * Two Interior Images *

Step 2 — Site Interview (Site Representative)

Site inspector shall interview the property owner, tenant, or a worker associated with the property. If these individuals are not readily available, the site inspector shall, as a last resort, interview agents or representatives associated with the property.

1. Site Representative Name & Position * 2. How long has Representative been associated with subject property? * 3. Current usage of the property and name of the business * 4. Does the site representative know the past usage of the property and name of business? * 5. Is Site Representative aware of any environmental concerns in connection with the property? If yes, please explain: * 6. Is Site Representative aware of any environmental concerns from neighboring properties that may pose risk? If yes, explain: * 7. Prior knowledge that the property was a gas station, dry cleaner, or industrial building in the past? If yes, explain: * 8. Is the representative aware of any pending, threatened, or past litigation/violations relevant to hazardous substances or petroleum products? If yes, explain: *

Step 3 — Observations & Potential Concerns

1. Above Ground Petroleum Storage Tanks

Did you observe any fuel tanks, propane tanks, compressed air and gas tanks/cylinders, or other above-ground storage tanks?

Yes No N/A

Comments: Above Ground Tank Images (up to 4):

2. Underground Petroleum Storage Tanks

Did you observe any of the following:

Unknown piping protruding from the ground? Evidence of underground tanks? Fuel dispensers? Lid covers indicating a possible underground storage tank? No

Comments: Underground Tanks Images (up to 4):

3. Petroleum Products *

Aside from petroleum products that you already identified above, did you observe any other petroleum products in containers?

NO YES N/A

Comments: Petroleum Products Images (up to 4):

4. Hazardous Substances

Aside from substances that you already identified above, did you observe any other hazardous substances?

NO YES N/A

Comments: Hazardous Substances Images (up to 4):

5. Unusual Odors

Did you smell any unusual odors?

NO YES N/A

Comments: Underground Tanks Images (up to 4):

6. Pools of Man-Made Liquid

Did you observe any pools of liquid?

NO YES N/A

Comments: Pools of liquid Images (up to 4):

7. Transformers / Hydraulic Equipment / PCBs

Did you observe any of the following:

Transformers Elevators Automobile lifts Other

Comments: Hydraulic Images (up to 4):

8. Pits, Ponds or Lagoons *

Did you observe any pits, ponds or lagoons?

NO YES N/A

Comments: Pits, Ponds or Lagoons Images (up to 4):

9. Significant Stains of Soil or Pavement *

Did you observe significant stains of soil or pavement?

NO YES N/A Limited Visibility

Comments: Stains Images (up to 4):

10. Stressed Vegetation Related to Contamination *

Did you observe dead or discolored vegetation related to contamination?

NO YES N/A

Comments: Vegetation Images (up to 4):

11. Solid Waste or Trash Debris *

Did you observe large open trash piles, mounds or depressions suggesting trash disposal or other solid waste concerns?

NO YES N/A

Comments: Waste Images (up to 4):

12. Wastewater *

Did you observe or were you provided any information from the site contact indicating any of the following:

Exterior drains, ditches or underground injection systems? Oil-water separators and/or manhole covers near vehicle wash/repair areas that may indicate the presence of an oil-water separator? No

Comments: Wastewater Images (up to 4):

13. Sewage Systems *

City Sewer or Septic?

City Sewer Septic City Sewer & Septic None On Site N/A

Comments: Sewage Type Images (up to 4):

14. Interior Heating/Cooling Systems *

Did you observe any interior heating and cooling systems?

NO YES N/A

Comments: Heating/Cooling System Images (up to 4):

15. Heating System Fuel Type *

What energy or fuel is used to heat the building?

Electric Natural Gas Propane Kerosene Heating Oil N/A Other (please specify)

Comments: Heating Fuel Images (up to 4):

16. Floor Drains & Sumps *

Did you observe any interior floor drains or sumps?

NO YES N/A

Comments: Drains Observed Images (up to 4):

17. Were there any interior or exterior areas not inspected or not permitted to inspect? 18. Additional details about the property (optional) Optional images (up to 4)

Step 4: Neighboring Properties

19. North neighboring property: Address & type of property or business. * North neighboring property images (up to 4)

20. South neighboring property: Address & type of property or business. * South neighboring property images (up to 4)

21. East neighboring property: Address & type of property or business. * East neighboring property images (up to 4)

22. West neighboring property: Address & type of property or business. * West neighboring property images (up to 4)

Step 5: Additional Images

Additional Images Notes :