applicant's environmental site declaration

APPLICANT’S ENVIRONMENTAL SITE DECLARATION

PART I: SITE LOCATION & HISTORY

PART II: ENVIRONMENTAL ASSESSMENT OF THE SITE Yes No Do not

F4089ENG (2016/04) – Ce formulaire est disponible en français (F4089FR) of 3

1. Applicant

2. Address

3. City/Town

4. Name & Address of Owner of propertySame as No. 1, 2 & 3

last 50 years:

5. Date of building construction

8. Historical use of the property over the

9. Current or planned use of the property:

10. Current use of adjacent properties:

6. Date occupied by current user

Province Postal Code

7. Any Environmental Assessments done in the past? Yes No

Agricultural Undeveloped Recreational Residential Commercial Industrial



Date: If yes, please attach reports.

1. Are there any underground or aboveground storage tanks on your property? If yes, please complete page 3 of this form.

2. Have underground or aboveground storage tanks been removed from the property? If yes, please complete page 3 of this form.

3. Do you have Storage Tank Pollution Liability Insurance that insures loss arising from the tanks and associated piping?If yes, please provide a copy of the policy.

4. Does the potable water come from: a) the municipality’s water distribution system, b) on site field well or artesian well or from groundwater), c) surface water, d) other? Please specify:

5. Does the water for industrial use come from: a) the municipality’s water distribution system, b) on site field well or artesian well or from groundwater), c) surface water, d) other? Please specify:

6. Is there contaminated groundwater or soil?

If yes, please specify:

7. Are any of the following in evidence: a) stained soil, b) areas of sparse, sick or dead vegetation, c) discoloured surface water or groundwater?


8. Does the property operate now or did it operate in past as a landfill (sanitary or not), junkyard, incinerator, landfill site for waste or other dumping area?

9. Are there or have there been any spills or polluting incidents on the site?


10. Has there ever been a complaint filed for environmental reasons? If yes, provide details:

11. Are there now or have there ever been any environmental orders or civil actions or other environmental concerns on the property or violations of permits or laws?

If yes, please provide information, dates and details of the current situation:

12. Are there activities undertaken on neighbouring properties that pose a risk to contaminate your property? If yes, please specify:

know

F4089ENG_INTERNATIONAL (02/2012) – Ce formulaire est disponible en français (F4089FR_INTERNATIONAL) of 3

PART III: SOCIAL RESPONSIBILITY

PART V: ENVIRONMENTAL CONTACTS

Name and Title (full name in print formatSigning Officer


PART III: SITE OPERATIONS AND PROCESSES

PART IV: ENVIRONMENTAL CONTACTS

Yes No

1. Are there operations and processes that require disposal and/or treatment (either onsite or offsite) of industrial wastes or by-products that could contaminate the soil or groundwater (e.g. hydrocarbon/water mixtures and emulsions, solid, liquid or gaseous chemical products, organic solvents or wastes, organic wood-preserving chemicals, infectious waste, radioactive waste, PCBs, etc.)? If yes, please specify:

• Type(s) of industrial wastes or by products:

• Volume being disposed/treated:

• Manner in which they are disposed/treated:

2. Are there discharges of wastewater (other than domestic sewage and water) into water bodies or into a sewerage system that contain industrial wastes or by-products (either treated or untreated)? If yes, please specify:

• Type(s) of industrial wastes or by products:

• Volume being treated/discharged:

• Manner in which they are treated/discharged:

-

-

3. Are you required to have specific permits or licences (all levels of government) for the disposal, treatment or discharge of industrial wastes or by-products? If yes, please provide copies.

4. Do you have Fixed Site Pollution Liability Insurance (also known as Environmental Impairment Liability (EIL), Environmental Site Liability (ESL), Pollution Legal Liability (PLL), Premises Pollution Liability (PPL)) that covers third party claims for bodily injury, property damage, clean-up costs and related legal expenses for pollution conditions on, at, under or migrating from the insured property. If yes, please provide a copy of the policy.

5. Have you ever had an external environmental compliance audit? If yes, please provide a copy of the report.

6. Are you ISO 14000 certified?

1. Environmental Consultant

2. Solid waste (hazardous waste) disposal company

3. Liquid waste disposal company

I hereby represent and warrant to the Business Development Bank of Canada and its agents that I am familiar with the property and to the best of my knowledge and belief based on the information in my possession, the foregoing declarations constitute a complete disclosure of the existing or potential environmental hazards and/or contamination pertaining to the property described above.

F4089ENG (2016/04) – Ce formulaire est disponible en français (F4089FR) Page 2 of 3

)Name and Title (full name in print format)Signing Officer Date

TELEPHONENAME & ADDRESS

Yes No Yes No

Did an environmental consulting firm analyze the soil and groundwater immediately following the removal of the tank?If yes, please attach a copy of the report.

Was the work super-vised by an environmen-tal consulting firm?If yes, please attach a copy of the report.

Abo

vegr

ound

or Und

ergr

ound

Tank

No.

Reason(s) for removal

Yea

r rem

oved

Type of material for tank/Contents

Age

of t

ank

Tank

siz

e (in

litre

s)

Yes No Yes No

an environmental consulting firm analyze the soil and groundwater immediately following the removal of the tank?If yes, please attach a copy of the report.

DidWas the work supervised by an environmental consulting firm?If yes, please attach a copy of the report.

F4089ENG (2016/04) – Ce formulaire est disponible en français (F4089FR) of 3


STORAGE TANK(S) – PRESENTLY ON SITE

STORAGE TANK(S) – REMOVED

Abo

vegr

ound

or Und

ergr

ound

Tank

siz

e (in

litre

s)

Tank

No.

Age

of t

ank

Type of material for tank /Type of protection (cathodic, double wall, containment dike, etc.)

Contents Has it ever leaked?

Yes No

If yes, please provide details. Does the tank comply with current governmental standards?

Yes No

Additional comments (if the above space allocation is insufficient):

Applicant’s initials:

APPLICANT’S DECLARATION ON THE ENVIRONMENT AND SOCIAL RESPONSIBILITY (outside Canada)

F4089ENG_INTERNATIONAL (02/2012) – Ce formulaire est disponible en français (F4089FR_INTERNATIONAL) Page 3 of 3

STORAGE TANK(S) – PRESENTLY ON SITE

STORAGE TANK(S) – REMOVED

Tank

No.

Tank

siz

e(in

litre

s)

Abo

vegr

ound

or Und

ergr

ound

Age

ofta

nk

Applicant’s initials:

ofta

nkA

geof

tank

Tank

siz

e(in

litre

s)

applicant's environmental site declaration

Documents