Environmental Risk Survey Form – USDA

Text Preview:
This form is available electronically.
 FSA-851                      U. S. DEPARTMENT OF AGRICULTURE                                                                   TYPES OF REVIEW:
 (09-20-01)                            Farm Service Agency                                                                          A. Initial Review

                                                                                                                                    B. Subsequent Review (Update 1)
                          ENVIRONMENTAL RISK SURVEY FORM
                                                                                                                                    C. Subsequent Update (Update 2)

Note: Please read instructions for completing before preparing this form.
PART A - SITE INFORMATION
1. Site Name                                                            2. Address (Include City, State, Zip Code and County)                      3. Case Number




4. Township                                                    5. Range                                                          6. Section


7. Directions to property: (From nearest town)




8. Nearest intersection                                        9. Property Size               1 0. Describe the current use of the property




11. Is the property or a portion thereof located in a 100-year floodplain?                    12. Are there any wetlands located on the property?

                               YES                            NO                                                                 YES                          NO

PART B - SITE OWNERSHIP HISTORY AND BACKGROUND
13A. Current Owner                                                      13B. Current Operator                                                      15. Date FSA became involved with
                                                                                                                                                       the property (Date of first loan
                                                                                                                                                       or application)

14. Previous owner(s):
A. Name:                                                                                      B. Dates owned:




PART C - SITE DATA
16. Are there any buildings on the property?                                                             NO              If ''YES'', complete Table 1.
                                                                               YES

TABLE 1 - Buildings or Other Structures. Insert the appropriate map symbol from Part F in column B
                                                                                                    D. Used for Chemical               E. Contains Lead
                                                                                  C. Year                                                                        F. Contains Asbestos
                A. Type of Structure                     B. Map Symbol                              Storage and or Mixing                 Based Paint
                                                                                     Built
                                                                                                   YES        NO      Unknown      YES        NO    Unknown    YES       NO     Unknown




Questions 17 through 24 are used to establish the present use of the property as well as any historical use which may be a contributing factor in any
present contamination concerns.
                                                                                                                                   A. Owner or Occupant        B. Observed During Visit
                                                          Question
                                                                                                                                   YES        NO    Unknown    YES       NO     Unknown

17. Has the property ever been used for industrial production such as a machine shop?

18. Have any adjoining properties been used for industrial production such as a machine shop?

19. Has the property ever been used for the production or exploration of petroleum?

20. Has the property ever been used as a base location for an aerial crop spraying or dusting service?
FSA-851 (09-20-01)                                                                                                                                                         Page 2 of 6

                                                                                                                                  A. Owner or Occupant      B. Observed During Visit
                                                                                                                                 YES       NO    Unknown     YES      NO      Unknown
21. Has a gasoline station or any other commercial activity that stored large amounts of solvents, pesticides
     or other chemicals ever operated on the property?
22. Has a gasoline station or any other commercial activity that stored large amounts of solvents, pesticides or other
    chemicals ever operated on any adjoining properties?
23. Has the property ever been used as a junkyard or landfill including a site where drums or other containers of
    chemicals were buried?
24. Have any adjoining properties ever been used as a junkyard or landfill including a site where drums or other
    containers of chemicals were buried?
25. Are there any USTs on the property which have been permanently closed?
26. Are there any environmental liens or judgements filed against the property as a result of not complying with
    Federal or State environmental laws?
27. Is the property involved in any lawsuits regarding environmental compliance issues?


28. Are there any chemical containers including 55-gallon drums used for pesticides or other hazardous substances located on the property?

           YES                  NO                  Unknown           If ''YES'', complete Table 2

TABLE 2 - Containers or Drums. Insert the appropriate map symbol from Part F in column B.

                                                                                                                    D. EPA Reg.            E. Estimated    F. Is the Container Leaking?
             A. Container Location                     B. Map Symbol              C. Container Contents
                                                                                                                     (if available)          Quantity
                                                                                                                                                             YES      NO      Unknown




29. Are there any abandoned or discarded automotive, tractor, farm machinery, industrial, or other batteries present on the property?

           YES                  NO                  Unknown           If ''YES'', provide the estimated quantity and location in Table 3

TABLE 3 - Batteries. Insert the appropriate may symbol from Part F in column B.
                                                                                                                                                           D. Are Any of the Batteries
                         A. Location of Batteries                                     B. Map Symbol                        C. Estimated Quantity                   Leaking?
                                                                                                                                                             YES      NO      Unknown




30. Are there any appliances, junk automobiles, tractors, farm machinery, abandoned tires, or other automobile or tractor related parts present on the property?

           YES                  NO                  Unknown           If ''YES'', provide the estimated quantity and location in Table 4

TABLE 4 - Abandoned Machinery, Tires or Other Equipment. Insert the appropriate map symbol from Part F in column B.
           A. Location of Appliances, Machinery, Tires or Parts                       B. Map Symbol                C. Estimated Quantity             D. Type of Tires or Parts
FSA-851 (09-20-01)                                                                                                                                                         Page 3 of 6

31. Are there any signs of fill dirt present on the property which might indicate covering of contaminants?                                                 YES       NO      Unknown
    If ''YES'', provide the location and map symbol:




32. Are there any areas of stained soil on the property? If ''YES'', provide the location and map symbol, and
    appropriate size. Also attach photographs.




33. Are there any areas of the property such as floors in buildings which are stained? If ''YES'', provide the location and map
    symbol for the affected buildings.




34. Are there any electrical transformers located on the property which are not labeled as ''PCB Free''? If ''YES'', provide the
    location and map symbol.




35. Does the property contain any USTs or above ground storage tanks (ASTs) currently in operation or which have been
    temporarily closed? If ''YES'', complete Table 5




TABLE 5 - Storage Tanks. Insert the appropriate map symbol from Part F in column C.
                                                            D. What
                                                             Type             E. If ''UST'', is it         F. Does the Tank                                  H. Is the Tank Known
                               B. Size if      C. Map                                                                                G. If ''YES'', What
     A. Tank Location                                                          Registered?              Contain Any Substance?                                   to be Leaking?
                                known          Symbol                                                                                    Substance
                                                           AST    UST
                                                                        YES         NO        Unknown    YES     NO      Unknown                            YES       NO      Unknown




PART D - WATER AND WASTE INFORMATION
36. Are there any lagoons, ponds or other liquid holding facilities present on the property?

             YES                  NO                Unknown             If ''YES'', complete Table 6

TABLE 6 - Lagoons, Ponds or Other Holding Facilities. Insert the appropriate map symbol from Part F in column C.
                                                                                                                                      E. Condition                F. Permitted or
      A. Lagoon, Pond, or Other Location                B. Size         C. Map Symbol                   D. Primary Use                                              Registered
                                                                                                                                   Good   Fair       Poor   YES       NO      Unknown
FSA-851 (09-20-01)                                                                                                                                                         Page 4 of 6

37. Are there any wells located on the property?

          YES                  NO                  Unknown            If ''YES'', complete Table 7

TABLE 7 - Wells. Insert the appropriate map symbol from Part F in column B.
                                                                                                                                 E. Described Condition
                                                        B. Map                        C. Use 1/                                                                   F. Construction
              A. Location of Well                                                                                D. Depth          of Well and Casing
                                                        Symbol
                                                                          D           I      O       A                           Good      Fair   Poor       Casing   Drilled    Dug




I/ ''D'' - Domestic "I" - Irrigation ''O'' - Other      ''A'' - Abandoned

38. If applicable, is there evidence of well contamination such as signs of using an area immediately adjacent to the well for the filling of spray tanks?

          YES                  NO                  Unknown          If ''YES'', please describe the signs or evidence of possible contamination along with the location of the
                                                                    well and supply the appropriate map symbol: (Attach copies of any water test results)




39. Is there any evidence or do you have prior knowledge that contaminants have been identified in either a well or water system with levels that exceed regulatory
    acceptable levels?
                                                                    If ''YES'', please describe the signs or evidence of possible contamination along with the location of the
          YES                  NO                  Unknown          well and supply the appropriate map symbol: (Attach copies of any water test results)




40. If drinking water is not obtained from a groundwater source on the property, where does the supply come from?




41. If a residence is located on the property, what type of waste or septic system is used? Describe condition of such system along with distance of system from any
    drinking water sources:




PART E - RECORDS SEARCH
                                                                                                                                                                          YES       NO
42. Are there any National Priority List (NPL) sites within 1 mile of the property?

43. Are there any Comprehensive Environmental Response, Compensation, and Liability Information System (CERCLIS) sites located within .5 mile of
    the property?


44. Are there any sites listed by the State within 1 mile of the property which are equivalent to NPL sites?


45. Based on State maintained data, are there any Leaking Underground Storage Tanks (LUST)? List sites located within I mile of the property?




46. Based on State maintained data, are there any solid waste landfill sites located within 1 mile of the property?
FSA-851 (09-20-01)                                                                                                Page 5 of 6

    PART F - SKETCH OF PROPERTY. (Draw outline of property boundary in blue ink.)




Legend and Map Symbols:
U         UST                                                   ++++   Railroad
A         AST                                                   PL     Pond or lagoon
R         Residence                                             D      Dump or other possibly contaminated site
B         Building                                              GB     Grain bin or silo
ST        Septic Tank and System                               WD      Well-Drinking Water
~~~       Creek, stream, river                                 WI      Well-Irrigation
===       Public road                                          WO      Well-Other
CM        Cemetery                                             WA      Well-Abandoned
          Private road or driveway                              SS     Stained Soil
BT        Batteries                                            W       Wetland
T         Tires                                                        Transformer
X         Barrel or drum                                        C      Containers
Download Link:
Share Link: Forum Link:

More on Science & Technology

  • Picture: Math Boxes - Everyday Math - Login

    Math Boxes – Everyday Math – Login

    File Size: 1,819.53 KB, Pages: 5, Views: 83,546 views

    Math Boxes Objectives To introduce My Reference Book; and to introduce the t Math Boxes routine. www.everydaymathonline.com ePresentations eToolkit Algorithms EM Facts Family Assessment Common Curriculum Interactive Practice Workshop Letters Management Core State Focal Points Teacher's GameTM Standards Lesson Guide Teaching the Lesson Ongoing Learning …
  • Picture: A Study of the Relationship Between Students Anxiety and

    A Study of the Relationship Between Students Anxiety and

    File Size: 72.91 KB, Pages: 7, Views: 69,798 views

    US-China Education Review B 4 (2011) 579-585 Earlier title: US-China Education Review, ISSN 1548-6613 A Study of the Relationship Between Students' Anxiety and Test Performance on State-Mandated Assessments Rosalinda Hernandez, Velma Menchaca, Jeffery Huerta University of Texas Pan American, Edinburg, USA This study examined whether …
  • Picture: HIGH-EFFICIENCY UPFLOW FURNACE INSTALLER'S  - Crown Boiler

    HIGH-EFFICIENCY UPFLOW FURNACE INSTALLER’S – Crown Boiler

    File Size: 534.22 KB, Pages: 27, Views: 63,768 views

    HIGH-EFFICIENCY UPFLOW FURNACE INSTALLER'S INFORMATION MANUAL D ES IG N CE R TI F I ED ATTENTION, INSTALLER! After installing the ATTENTION, USER! Your furnace installer should furnace, show the user how to turn off gas and electricity to give you the documents listed on …
  • Picture: Raven/Johnson Biology 8e Chapter 12 1.

    Raven/Johnson Biology 8e Chapter 12 1.

    File Size: 99.62 KB, Pages: 9, Views: 41,253 views

    Raven/Johnson Biology 8e Chapter 12 1. A true-breeding plant is one that-- a. produces offspring that are different from the parent b. forms hybrid offspring through cross-pollination c. produces offspring that are always the same as the parent d. can only reproduce with itself The …
  • Picture: Math Skills for Business- Full Chapters 1 U1-Full Chapter

    Math Skills for Business- Full Chapters 1 U1-Full Chapter

    File Size: 3,860.88 KB, Pages: 188, Views: 43,688 views

    Math Skills for Business- Full Chapters 1 U1-Full Chapter- Algebra Chapter3 Introduction to Algebra 3.1 What is Algebra? Algebra is generalized arithmetic operations that use letters of the alphabet to represent known or unknown quantities. We can use y to represent a company's profit or …

Leave a Reply

Your email address will not be published. Required fields are marked *