HAZARDOUS MATERIALS FIELD INSPECTION CHECKLIST

A.	BACKGROUND INFORMATION

  Clear Form 

NRCS PROGRAM	LANDOWNER NAME	
PROPERTY ADDRESS	NUMBER OF ACRES	
NEST APPLICATION NUMBER	COUNTY	STATE	
FIELD INSPECTOR’S NAME & TITLE	DATE INSPECTED	
B.	INSTRUCTIONS:
•	For each question, indicate if you find any evidence of past or present hazardous materials.
•	For any suspected evidence found, display the location on the parcel map and attach photographic evidence as an addendum to this document.
•	If you need more room to explain your findings attach additional sheets.
•	When complete, attest that a field inspection has been completed and that to the best of your knowledge the information included is accurate.
C.	
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Field Conditions:	Onsite	Nearby	None
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Dumps or landfills (especially with drums/containers)
2.	Other debris: household or farm waste
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Fills (possible cover for dumps)
4.	Unusual chemical odors
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Above/below ground storage tanks
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Buildings: chemical storage, equipment repair solvents
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Structures: evidence of asbestos
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Vegetation different from surrounding area for no apparent reason (e.g., stressed or dead, bare ground)
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"Sterile" or modified water bodies
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Oil seeps, stained ground, discolored stream banks
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Unnatural characteristics of water: oil slicks, unusual color, etc.
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Spray operation base: air strip, equipment parking area chemical staging, storage, and mixing areas
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Machinery repair areas
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Pipelines, power lines, gas lines
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Oiled or formerly oiled roads
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Mounted transformers - evidence of leakage
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Any mining activity or mining residue: past, present, or future
18.	Wastewater treatment equipment, septic system, sewage lagoons
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19.	Treatment for vegetation or invasive species
20.	Spills or releases of pollution
D.	
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EVIDENCE OF PAST USE (check all that are applicable) Manufacturing

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Service station Dry cleaning Air Strip Pipeline Railroad line

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Facilities with large electrical transformers Petroleum production
Landfills

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Scrap metal, auto, or battery recycling Military

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Laboratories Wood preserving Tanning Monitoring wells

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Wells no longer providing water Piles of soil, rock, debris
Any unnatural topographic features

Other (describe)  	

E.	PHYSICAL EVIDENCE OF EASEMENTS OR RIGHTS-OF-WAY (power lines, pipelines, railroads, roads)

F.	NEARBY LAND USES: (describe all surrounding land uses – especially those upstream or upgradient)
G.	CONTAMINATED SITES RECORD SEARCH:
List all known contaminant sites within a 1-mile radius of the site. Check with Federal or State environmental protection agencies and local authorities. Are there any known hazardous material problems on or near the site (National Priority List, State sites, etc.)? (Attach additional sheets as necessary)
H.	INTERVIEWS:		(Interviewee Name)	(Title)	(Interview Date) Present Owner(s)       				                                                                                                                                              Past Owner(s)	 				                                                                                                                                              County Agent	 				
A.	

Other Authorities	 	

I.	AGRICULTURAL HISTORY:
Type, Duration and Extent of Agricultural Activity:
Surface Drains Present	       PRESENT	        NOT PRESENT

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Subsurface Drains Present	       PRESENT	       NOT PRESENT
J.	RECOMMENDATION:

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In my professional opinion and based on my inspection of the site this project should move forward: YES	 NO	 FURTHER INVESTIGATION NEEDED
K.	CERTIFICATION:
I hereby certify that on 	, 20 	I made a personal examination and inspection of the tract or parcel of land identified above, and that I am fully informed as to the boundaries, lines and corners of said tract. Based upon a careful and thorough investigation and inquiry I hereby certify that the Hazardous Materials Field Inspection Checklist and the attachments are true to the best of my knowledge and belief.

EXAMINER (Name and Signature)	OFFICIAL TITLE