ANTHC :: Brownfields Inventory

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Brownfield Inventory Form

date:
Name of community:

Name of person completing form:

What is the name of the site?:

What is the location of the site?:

Who is the current owner of the property? Include contact information if available.:

Is there is a building on the site? If so, when was it constructed?:

What is the approximate size of the site? :

Describe the site's current use:

Explain the known history of the site and how it has been used over time:

What is the approximate proximity of the site to public buildings or residences?:

Do subsistence activities occur at or near the site? If yes, what kind?:

Are children or animals attracted to the site?:

Describe any known or potential sources of contamination:

If you know of a specific spill, when did it occur and who was responsible for it?:

Estimate the quantity of the spill (weight or volume) and the size of the contaminated area:

Was there any cleanup done? If yes, who would have additional information?:

Is there a perceived health concern associated with the site? If yes, what is the concern?:

Was the DEC, EPA or any other agency involved with this issue at any time in the past? If yes, when and what were the results?: