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Lter�t� <br /> Rev 2/23/2001 <br /> 5; �Pr ' 1 !�4• Page I ot6 <br /> F N ' ! 5 s r ( TRANSACTION SCREEN QUESTIONNAIRE <br /> This questionnaire has been prepared by Condor Earth Technologies, Inc (Preparer) by request <br /> from (User) in order to obtain information regarding the proposed (Site) The <br /> objective of this questionnaire is to provide the User with information regarding the presence or <br /> likely presence of any hazardous substances or petroleum products on the property that may <br /> present a material i risk of harm to public health or to the environment Infonisation provided by <br /> this questionnaire will be used to identify recognized environmental conditions existing on the <br /> Site that may or may not require additional research The questionnaire is provided on a <br /> voluntary basis by the respondent as part of a customary practice for conducting an <br /> Environmental Site Assessment on a specific parcel of real estate Please respond to the best of <br /> your ability To provide further information, please describe reason for any affirmative answers <br /> on a separate sheet of paper <br /> RESPONDENT(CHECK ONE) <br /> Owner Occupant ] Preparer(during Site visit) <br /> Question Answer <br /> la Is this Site used for an industrial use? Yes No' Unk <br /> i I b Is any adjoining property used for an industrial use? Yes No : Unk <br /> 2a Did you observe evidence or do you have any prior Yes No Unk <br /> knowledge that the property has been used for an industrial <br /> ` use in the past? <br /> 2b Did you observe evidence or do you have any prior Yes No' Unk <br /> knowledge that any adjoining property has been used for an <br /> industrial use in the past? <br /> 3a Is the property used as a gasoline station,motor repair Yes No Unk <br /> facility, dry cleaners,photo developing laboratory, <br /> ,junkyard of landfill, or as a waste treatment, storage, <br /> disposal, processing, or recycling facility(if applicable, <br /> tdertify which)? <br /> 3b Is any adjoining property used as a gasoline station, Yes No Unk <br /> motor repair facility, dry cleaners, photo developmg <br /> laboratory,_junkyard of landfill,or as a waste treatment, <br /> storage, disposal, processing, or recycling facility(if <br /> applicable, identify which)? <br /> t <br /> 4a Did you observe evidence or do you have any prior Yes No Unk <br /> knowledge that the property has been used as a gasoline <br /> station, motor repair facility, dry cleaners, photo developing <br /> laboratory,.junkyard of landfill, or as a waste treatment, <br /> storage, disposal, processing, or recycling facility(if <br /> . applicable, identify which)? <br /> a <br /> Initials <br />