Residential Property ESA Historical Use Questionnaire

Property Information

Property Address Owner's Name Contact Information

Site History

Year Property Was Built Past Uses of the Property Known Modifications or Renovations

Environmental Concerns

Underground or Aboveground Storage Tanks Yes No Unknown If yes, please describe Use, Storage, or Disposal of Hazardous Materials Yes No Unknown If yes, please describe

Surrounding Properties

Current or Past Uses of Adjacent Properties Potential Environmental Issues Nearby

Additional Comments

Other Relevant Information