2. Submitter Details
4. Submitted By*
6. Email*
7. Phone
11. Submission Site Details
13. Site Name*
15. Address
17. Apartment, Suite, or Building
19. City
20. State
21. Postal / Zip Code
23. Current Site Owner*
25. Is there a known contamination at the site?*

    1. Yes
    2. No
27. If yes, briefly describe
31. Have any of the following previously been performed?
33. Phase II ESA?*

    1. Yes
    2. No
    3. Unknown
34. If yes, is a report available?

    1. Yes
    2. No
36. Environmental Site Investigation?*

    1. Yes
    2. No
    3. Unknown
37. If yes, is a report available?

    1. Yes
    2. No
39. Environmental Cleanup Activities?*

    1. Yes
    2. No
    3. Unknown
40. If yes, is a report available?

    1. Yes
    2. No
44. Which of the following would you like performed on this site?
46. Phase I ESA*

    1. Yes
    2. No
    3. Maybe
47. Phase I ESA Update*

    1. Yes
    2. No
    3. Maybe
49. Phase II ESA*

    1. Yes
    2. No
    3. Maybe
51. Additional Investigation to Define the Nature and Extent of Previously Documented Impacts

    1. Yes
    2. No
    3. Maybe
53. Asbestos Inspection and / or Assessment for Other Hazardous Building Materials

    1. Yes
    2. No
    3. Maybe
55. Market Research Study

    1. Yes
    2. No
    3. Maybe
57. "Mini" Reuse Plan

    1. Yes
    2. No
    3. Maybe
59. Summarize why this site is a priority for assessment.*
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61. 1. Receive an email copy of this form.
62. Email address

    This field is not part of the form submission.

63. Submit

* indicates a required field