Appendix B: Screen Form

Phase1 - Environmental Site Assessment
Report
Appendix B

APPENDIX B: PHASE 1 SITE ASSESSMENT - SCREEN FORM
(ASTM E1528-96/CSA Z768-94)

Date:	Interviewer Name:
Plant Name:	Interviewee Name/Position:
Plant Address:

	Response/Comments
Is any adjoining property used for an industrial use?	Yes	No	Unk	Yes	No
Did you observe evidence or do you have any prior knowledge that the property has been used for an industrial use in the past?	Yes	No	Unk	Yes	No
Did you observe evidence or do you have any prior knowledge that any adjoining property has been used for an industrial use in the past?	Yes	No	Unk	Yes	No
Is the property used as a gasoline station, motor repair facility, commercial printing facility, dry cleaners, photo developing laboratory, junkyard or landfill, or as a waste treatment, storage, disposal, processing, or recycling facility (if applicable, identify which)?	Yes	No	Unk	Yes	No
Is any adjoining property used as a gasoline station, motor repair facility, commercial printing facility, dry cleaners, photo developing laboratory, junkyard or landfill, or as a waste treatment, storage, disposal, processing, or recycling facility (if applicable, identify which)?	Yes	No	Unk	Yes	No
Did you observe evidence or do you have any prior knowledge that the property has been used as a gasoline station, motor repair facility, commercial printing facility, dry cleaners, photo developing laboratory, junkyard or landfill, or as a waste treatment, storage, disposal, processing, or recycling facility (if applicable, identify which)?	Yes	No	Unk	Yes	No
Did you observe evidence or do you have any prior knowledge that any adjoining property has been used as a gasoline station, motor repair facility, commercial printing facility, dry cleaners, photo developing laboratory, junkyard or landfill, or as a waste treatment, storage, disposal, processing, or recycling facility (if applicable, identify which)?	Yes	No	Unk	Yes	No
Are there currently any damaged or discarded automotive or industrial batteries, pesticides, paints, or other chemicals in individual containers of >5 gal (19L) in volume or 50 gal (190L) in the aggregate, stored on or used at the property or at the facility?	Yes	No	Unk	Yes	No
Did you observe evidence or do you have any prior knowledge that there have been previously any damaged or discarded automotive or industrial batteries, or pesticides, paints, or other chemicals in individual containers of >5 gal (19L) in volume or 50 gal (190L) in the aggregate stored on or used at the property or at the facility?	Yes	No	Unk	Yes	No
Are there currently any industrial drums (typically 55 gal (208 L)) or sacks of chemicals located on the property or sacks of chemicals located on the property or at the facility?	Yes	No	Unk	Yes	No
Did you observe evidence or do you have any prior knowledge that there have been previously any industrial drums (typically 55 gal (208 L)) or sacks of chemicals located on the property or at the facility?	Yes	No	Unk	Yes	No
Did you observe evidence or do you have any prior knowledge that fill dirt has been brought onto the property that originated from a contaminated site?	Yes	No	Unk	Yes	No
Did you observe evidence or do you have any prior knowledge that fill dirt has been brought onto the property that is of an unknown origin?	Yes	No	Unk	Yes	No
Are there currently any pits, ponds, or lagoons located on the property in connection with waste treatment or waste disposal?	Yes	No	Unk	Yes	No
Did you observe evidence or do you have any prior knowledge that there have been previously, any pits, ponds, or lagoons located on the property in connection with waste treatment or waste disposal?	Yes	No	Unk	Yes	No
Is there currently any stained soil on the property?	Yes	No	Unk	Yes	No
Did you observe evidence or do you have any prior knowledge that there has been previously, any stained soil on the property?	Yes	No	Unk	Yes	No
Are there currently any registered or unregistered storage tanks (above or underground) located on the property?	Yes	No	Unk	Yes	No
Did you observe evidence or do you have any prior knowledge that there have been previously, any registered or unregistered storage tanks (above or underground) located on the property?	Yes	No	Unk	Yes	No
	(continued on next page)

APPENDIX B: PHASE 1 SITE ASSESSMENT - SCREEN FORM (ASTM E1528-96/CSA Z768-94)

APPENDIX B: PHASE 1 SITE ASSESSMENT - SCREEN FORM
(ASTM E1528-96/CSA Z768-94)