General Assessment Form

Name*

Mailing Address

City, State, Zip

Phone

Email

Name of Business of Concern:

Address of Location of Concern:

Approximate Building Square Footage:

Approximate Square Footage of Land:

How long have you operated at this site?

Did someone operate before or after you?

Do you own or lease this site?

List hazardous materials that have been used at this site:

Did you purchase general liability insurance for your business?

How did you hear about us?:

Additional Notes