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I <br /> MATERIAL QTY DATE(S) COMMENTS <br /> OBSERVED <br /> Vent pipes, fill pipes, access Location: 111 <br /> ways to a fill pipe protruding <br /> from the ground or adjacent <br /> to a structure onsite? <br /> Heating and cooling systems Source: <br /> (include fuel source) <br /> Flooring, drains, walls that Location: <br /> are stained or emitting a foul <br /> odor (do NOT include water <br /> damage)? <br /> *Please provide records if available. <br /> 8. Is the property served by a private well or non-public water system? If so, please answer <br /> the following: O <br /> a. Was the well used for domestic(D), agricultural irrigation (I), or monitoring (M) <br /> purposes? Are the wells currently operational and if not, when were they last used? <br /> When was the well drilled? How deep is the well? What is the approximate discharge <br /> rate? <br /> Well Last Date Discharge <br /> No. Type Operating? Used Drilled Rate Location <br /> 1- <br /> 2- <br /> b. Have the wells been sampled for contaminants that exceed applicable requirements for <br /> the designated use (e.g. Drinking Water Standards)? If so, please provide the dates and <br /> copies of well records. <br /> c. Has the well or water system been designated by any governmental I <br /> environmental/health agency as contaminated? <br /> 9. Is there an oil/gas well or oil/gas vent located onsite? If so, please indicate the location. <br /> Please supply any documents available. <br /> Q\ (7 <br /> 1 <br /> 10. Is the property or has the property to your knowledge been previously served by a septic <br /> system? If so, please indicate the location of the tank and leach lines (if applicable) and list <br /> any hazardous materials disposed. <br /> 73 <br /> I <br /> 4 <br />