Soil Contamination Preliminary Evaluation Questionnaire
Site Information
Site Name
Location/Address
Contact Person
Contact Number
Site History
Describe current and historical use of the site
Potential Sources of Contamination
Are there or have there been any of the following on site?
Underground/Aboveground Storage Tanks
Fuel Storage/Dispensing
Waste Disposal/Dumping
Industrial Operations
Pesticide/Herbicide Application
If yes, please provide details
Visible Indicators
Are there any visible signs of contamination?
Soil Staining
Unusual Odors
Debris or Wastes
None Observed
If yes, provide description and location
Nearby Sensitive Areas
Are there any of the following within 500 meters of the site?
Schools/Playgrounds
Residential Areas
Surface Water
Wells
None Observed
Provide details if applicable
Additional Comments