**Suspense Date:** [DATE DUE]{.underline}

SITE QUESTIONNAIRE FOR INVENTORY OF POTENTIAL

SURFACE AND GROUND WATER CONTAMINANT SOURCES

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less.**)

**Activity/Unit Name:**
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**Nature of activity** (communication, food service, vehicle repair,
etc.):
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Proper name of facility:**
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Kind of facility:**

\_\_ Building \_\_ Parking area (please circle) paved/unpaved,
covered/uncovered

\_\_ Range \_\_ Open storage (please circle) paved/unpaved,
covered/uncovered

\_\_ Other (specify):
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Location** (building number, street address or description):
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

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**Nearest well and/or watercourse** (see attached map):
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Date of this inventory:** \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Name of person(s) supplying information:**
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Year facility began operation:** \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Previous use(s) of site:**
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Who should be contacted if a site visit is required?**
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Materials handled on site (please circle).** Name specific chemicals
if appropriate.

1.  PCB

2.  Dioxin

3.  Gasoline

4.  Diesel Oil

5.  Other Distillate Fuel

6.  Asphalt or Other Residual

7.  Animal or Vegetable Oil

8.  Waste Oil

9.  Other Oil

10. Petroleum Solvents

11. Naptha

12. Mineral Spirits

13. Vermin Poisons

14. Insecticides

15. Nematicides

16. Herbicides

17. Fungicides

18. Antibiotics

19. Fertilizers

20. Metals

21. Acids

22. Organic Solvents

23. Caustics

24. Alcohols

25. Amines

26. Aldehydes

27. Radiological

28. Brines

29. Medical Waste

30. Other Biological

31. Oxidizers

32. Ammunition or Propellants

33. Unexploded Ordinance (UXO)

34. Open Burning/Open Demolition (OBOD)

35. Road Salts and Ash

36. Other (specify: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Comments:**
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**For questions, please contact:**

NAME AND TELEPHONE NUMBER OF INFORMATION CONTACT

**Please return completed form to:**

NAME OF INSTALLATION ENVIRONMENTAL OFFICE, CONTACT, AND TELEPHONE NUMBER