Instructions

• ALLrelevantSectionsofthePhase1EnvironmentalSiteAssessmentChecklistmustbecompletedandmustaccompanythePhase1EnvironmentalSiteAssessment(ESA)Report.

• ThesignaturerequiredonthischecklistisfromthemanagingSiteProfessional.

• Allregulatoryprotocolsmustbefollowedandallforms/checklistsmustbecompletedseparatelyforeachproperty.Thismeansthatasourcepropertyandanimpactedthirdpartypropertymusthavealldocumentsfiledseparately.Oncethesourcepropertyorimpactedthirdpartypropertyisidentifiedbythecheckboxbelow,allsubsequentreferenceonthisform/checklistaretothatsiteowner.

• Forms/checklistsmustbecompletepriortofilingwiththeMinister.

1 - Site Location and Contact Information

Detailsprovidedonthisformareapplicableto q  SourceProperty OR q  ImpactedThirdPartyProperty

Site Location

Mandatorymustbecompleted.

SiteAddress____________________________________________________ City___________________

ParcelIdentificationNumber(PID) ___________________________________ PostalCode_____________

Additionalinformation,LotNo.,GPS,locationrelativetolandmark,etc._____________________________________________________________

Property Owner

Mandatorymustbecompleted.

Name _________________________________________________________ Phone_________________

Email__________________________________________________________ Fax ___________________

CompanyName(ifapplicable)_______________________________________ City___________________

MailingAddress__________________________________________________ PostalCode_____________

Recognized Agent

ThissectionisOptional.

Name__________________________________________________________ Phone_________________

Email__________________________________________________________ Fax ___________________

CompanyName__________________________________________________ City___________________

MailingAddress__________________________________________________ PostalCode_____________

Contact for correspondence if different than above.

ThissectionisOptional.

Name__________________________________________________________ Phone_________________

Email__________________________________________________________ Fax ___________________

CompanyName(ifapplicable)_______________________________________ City___________________

MailingAddress__________________________________________________ PostalCode_____________

Site Professional

Contact Information Name _________________________________________________________ Phone_________________

Email__________________________________________________________ Fax ___________________

CompanyName__________________________________________________ City___________________

MailingAddress__________________________________________________ PostalCode_____________

2 - Site Assessment Requirements

Site Assessment Requirements SupportingInformation

provided

Reference Document

The following information has been investigated. Where information not available, or not applicable, section and page number must be provided where justification or absence has been documented. The Site Professional must ensure all work has been completed in accordance with PRO-300, Phase 1 Environmental Site Assessment Protocol.

Yes Section PageNumber

Records ReviewAllavailablerecordsrelatedtoknownorpossiblecontaminationoftheproperty,mustbeobtained,reviewedandreported,fromthefirstknowndevelopedusetotheconclusionofthePhase1ESA,includingthefollowing

1 Ownernamesanddatesofownershipforthepropertybasedonasearchofthepropertythatcommenceswiththedateofthefirstknowndevelopeduseoftheproperty

q

2 Anyoperators,leases,ortenantsofthepropertyowner,andadescriptionofanyoperationsoruseoftheproperty

q

Phase 1 Environmental Site Assessment ChecklistForallsitesundergoingFullPropertyRemediationandL3sitesundergoingLimitedRemediationEnvironment

Document No.: CHK-300 Page 1 of 4 Revision January 5, 2015

NSEFile#:

Site Assessment Requirements SupportingInformation

provided

Reference Document

The following information has been investigated. Where information not available, or not applicable, section and page number must be provided where justification or absence has been documented. The Site Professional must ensure all work has been completed in accordance with PRO-300, Phase 1 Environmental Site Assessment Protocol.

Yes Section PageNumber

3 Aerialphotographsthatillustrateasmuchaspossibletheperiodfromthestudyarea’sfirstdevelopedusetothetimeofthePhase1ESA

q

4 Siteandbuildingplansofpastandexistingpropertyuse,includingfireinsurancerecords,municipallanduseplans,andanyotherinformationthatmaybeavailablefromhistoricallyarchivedsources

q

5 Mapsandreportsthatprovideregionalinformationconcerninggeologicalconditionspertainingtothetypeofsoilandbedrockintheareawherethepropertyislocated

q

6 Topographicmaps q

7 Environmentalsiteassessmentreports,orpreviouslycompletedPhase1ESAreports q

8 Contaminatedsiteremediationreports,includingremedialactionplans q

9 Reportspreparedinresponsetoanorderordirectiveofaninspector,administratorortheMinister

q

10 Environmentalrecordsobtainedfromgovernmentsources,includingmunicipal,provincialorfederalauthoritiesandregulatoryagencies

q

11 Drilledwellreports q

12 Anyotherreports,includingreleasesandspillsrelatingtothepresenceofacontaminanton,inorundertheproperty,ortheexistenceofanareaofpotentialenvironmentalconcernthatmayorhascausedcontaminationoftheproperty

q

13 Subsurfaceutilitylocations q

14 Hydraulicliftlocations q

15 Anyinventoriesofchemicals,chemicalusageandchemicalstorageareasthathaveormayhavecausedcontamination,includingmaterialsafetydatasheets

q

16 Anyrecordsofabovegroundstoragetanksandundergroundstoragetanks q

17 Anydetailsofoil/waterseparatorsatthepropertyincludingforeachseparatorthelocation,installationdate,sourceofincomingliquidandeffluentdischargelocation

q

18 Allvehicleandequipmentmaintenanceareas,includingthelocationsofmaintenance,fluidstorage,andwastestorageareas

q

19 Detailsofallspillsincludingthedates,locations,materialsinvolved,andvolumesofmaterialspilled

q

20 DetailsofliquiddischargepointssuchaswaterandFrenchdrains,includinglocations q

21 Anyprocessorpropertyuserelateddocumentsthatmayrelatetopotentialoractualcontamination,includingwastemanagementrecords,environmentalmonitoringdataandenvironmentalmanagementsystemrecords

q

22 Availablerecordshavebeenobtained,reviewedandreportedforpropertiesimmediatelyadjacenttothesubjectproperty,orotherwiseasdeterminedanddocumented.Availablerecords,including:aerialphotographs,publicallyavailablemunicipallanduserecordsandfireinsuranceplans,currentandpastownershipinformationrelatedtopropertyuse,environmentalrecords,includingdrilledwatersupply(wellrecords),obtainedfromgovernmentsources,includingmunicipal,provincialorfederalauthoritiesandregulatoryagencies.environmentalmanagementsystemrecords

q

23 AllsourcesofinformationobtainedandreviewedaspartoftherecordsreviewcomponentmustbedocumentedhavebeenincludedinthePhase1ESAreport,includingsourcescheckedthatprovidednorelevantinformation

q

Site VisitAsitevisithasbeenconductedaspartofaPhase1ESAtoassess,document,collectandreportonthefollowing,asaminimum

24 Photographsofthepropertyandsurroundingpropertiesinalldirections,includingawrittendescriptionofthephotographs,withreferencetoanyrelevantinteriororexteriorstructuresorinfrastructureonthepropertythatmayrelatetopotentialoractualcontaminationofthesite

q

Document No.: CHK-300 Page 2 of 4 Revision January 5, 2015

Phase 1 Environmental Site Assessment ChecklistEnvironment

Site Assessment Requirements SupportingInformation

provided

Reference Document

The following information has been investigated. Where information not available, or not applicable, section and page number must be provided where justification or absence has been documented. The Site Professional must ensure all work has been completed in accordance with PRO-300, Phase 1 Environmental Site Assessment Protocol.

Yes Section PageNumber

25 Confirmationofpropertylanduseandimmediatesurroundinglanduse,structurespresentonthepropertyandtheirgenerallocation,andrelevantsitefeatures,includingadescriptionofanydrinkingwatersupplies,watercoursespresentonsite,andsurfacewaterdrainagefromtheproperty,includingstormwaterdrainage

q

26 Topographicconditionsonandoffthepropertyhavebeenobservedandnoted,includingthesitegradient,direction,andthetypeofvegetationorgroundcoverontheproperty

q

27 Confirmationofwatersupplylocationandcondition q

28 Confirmationofthelocationandconditionofstructuresusedforanypreviousenvironmentalactivityincludingmonitoringwells,remediationwells,in-situtreatmentzonesandvapourextractionsystems

q

29 Confirmationofthelocationandconditionofanypreviousremediationexcavationsandsoilremoval

q

30 Presenceofanyopensubsurfacefeaturessuchaslagoons,pits,trenchesandexcavations q

31 Ifknown,detailsofallstoragetanksandcontainers,aboveandbelowgroundattheproperty,includingthematerialandmethodofconstructionofeach,age,contentsandvolume,andwhetherthetankorcontainerisinuseornot

q

32 Confirmationandapproximatelocationofundergroundutilityandservicecorridors,includingsumpsandfloordrains,sewer,water,electricalorgaslines,andtelephone/fibreopticinfrastructurelocatedon,inorundertheproperty

q

33 Areasofstainedsoil,vegetationorpavement q

34 Stressedvegetation q

35 Areaswherefillanddebrismaterialsappeartohavebeenplacedorgraded q

36 Potentiallycontaminatingactivity q

37 Detailsofanyunidentifiedsubstancesfoundattheproperty,includingcontainertype,volumeandphysicalstate(solidsorliquids)

q

38 Hazardousmaterialspresentontheproperty q

39 Presenceofodoursdetectedduringthesitevisitthatmayberelatedtothepropertyandpotentialforcontamination

q

40 Anylimitationsrelatedtovisualobservations,includingobstructionsrelatedtobuildings,sitefeatures,safetyissuesimpedingaccess,andweatherrelatedconditionsaffectingvisibilityandgroundcoveratthetimeofthesitevisit

q

41 Confirmationofothersignificantinformationarisingfromthereviewofavailablerecords q

Interviews

42 Alistofallpersonsidentifiedtobeinterviewedandtheircurrentstatusorconnectionwiththepropertyinquestion

q

43 Alistofthosepersonsidentifiedbutnotinterviewed,withreasonswhytheywerenotinterviewed

q

ReportingInformationobtainedfromtherecordsreview,sitevisit,andinterviewshasbeensummarizedinafinalreportwhichprovidesthefollowing:

44 AlltherelevantfindingsconsistentwiththerequirementsofthePhase1ESAandpresentstheseinaclear,organizedmannerthatidentifiesthepotentialoractualcontaminationoftheproperty,supportedbytherationaleandbasis

q

45 Thepotentialoractualchemicalsofconcernandaffectedmediaidentifiedattheproperty q

46 Adistinguishingoffactualinformationfromprofessionalopinion q

Document No.: CHK-300 Page 3 of 4 Revision January 5, 2015

Phase 1 Environmental Site Assessment ChecklistEnvironment

Site Assessment Requirements SupportingInformation

provided

Reference Document

The following information has been investigated. Where information not available, or not applicable, section and page number must be provided where justification or absence has been documented. The Site Professional must ensure all work has been completed in accordance with PRO-300, Phase 1 Environmental Site Assessment Protocol.

Yes Section PageNumber

47 Theidentificationofthepotentialoractualcontaminationoftheproperty,supportedbytherationale

q

48 Theidentificationofthepotentialoractualchemicalsofconcernandaffectedmediaattheproperty

q

49 AlllimitationstocarryingoutandfulfillingtherequirementsofperformingthePhase1ESAinaccordancewithPRO-300,Phase 1 ESA Protocol,including:adescriptionofthelimitationrelatedtotherequirement,therationalefornotfulfillingtherequirementandthesignificanceofthelimitationrelatedtothefindings

q

3 - Declaration

Site Professional Declaration

IacknowledgeitisanoffenceunderSection158oftheEnvironment Acttoprovidefalseormisleadinginformation,andconfirmtothebestofmyknowledgeandbelieftheinformationprovidedinthisformandsupportingdocumentationistrueandaccurateandcomplieswiththerelevantprovisionsoftheEnvironment ActandContaminated Sites Regulations.Bysigningbelow,Iconfirmmyqualificationsandliabilityinsuranceasasiteprofessionalasprescribedwithintheregulations.

q  Reportsandchecklist/shavebeenprovidedtoaffectedpropertyowner.

Name(Print)__________________________________________ ProfessionalRegistrationNumber/Stamp_________________

Signature __________________________________________ Date _______________________ SiteProfessional MM/DD/YYYY

Return completed form and associated documents to the Department of Environment Regional Office.TofindyourRegionalOfficegoonlineatnovascotia.ca/nse/dept/division.emc.asp#centralorcall1-877-936-8476

Document No.: CHK-300 Page 4 of 4 Revision January 5, 2015

Phase 1 Environmental Site Assessment ChecklistEnvironment