Historical Land Use Assessment Questionnaire

Site Information

Site Name Site Address Site Area (hectares) Coordinates

Ownership Details

Current Owner Name Period of Ownership

Historical Use

List all known previous uses of the site Time periods for each use Description of historical buildings or structures on the site

Contamination & Activities

List known chemicals/substances used or stored Describe any industrial/agricultural/other activities Evidence or knowledge of dumping/burial of waste

Environmental Observations

Unusual soil/surface conditions Unusual odours noticed on site Vegetation stress or unusual growth

Additional Information

Relevant documents, maps, or photographs available Additional Notes