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U.S. Department of Agriculture <br />Natural Resources Conservation Service Hazardous Materials Field Inspection Checklist <br />1 <br />□ □ <br />□ □ <br />□ □ <br />□ □ □ <br />□ <br />□ <br />□ □ <br />□ □ □ <br />□ □ □ <br />□ <br />□ □ □ <br />□ □ <br />□ □ □ <br />□ □ <br />□ □ <br />□ <br />HAZARDOUS MATERIALS FIELD INSPECTION CHECKLIST <br />A.BACKGROUND INFORMATION Clear Form <br />NRCS PROGRAM LANDOWNER NAME <br />PROPERTY ADDRESS NUMBER OF ACRES <br />NEST APPLICATION NUMBER COUNTY STATE <br />FIELD INSPECTOR’S NAME & TITLE DATE INSPECTED <br />B.INSTRUCTIONS: <br />•For each question, indicate if you find any evidence of past or present hazardous materials. <br />•For any suspected evidence found, display the location on the parcel map and attach photographic evidence as an <br />addendum to this document. <br />•If you need more room to explain your findings attach additional sheets. <br />•When complete, attest that a field inspection has been completed and that to the best of your knowledge the <br />information included is accurate. <br />C.Field Conditions:Onsite Nearby None <br />1.Dumps or landfills (especially with drums/containers) <br />2.Other debris: household or farm waste <br />3.Fills (possible cover for dumps) <br />4.Unusual chemical odors <br />5.Above/below ground storage tanks <br />6.Buildings: chemical storage, equipment repair solvents <br />7.Structures: evidence of asbestos <br />8.Vegetation different from surrounding area for no apparent reason <br />(e.g., stressed or dead, bare ground) <br />9."Sterile" or modified water bodies <br />10.Oil seeps, stained ground, discolored stream banks <br />11.Unnatural characteristics of water: oil slicks, unusual color, etc. <br />12.Spray operation base: air strip, equipment parking area chemical <br />staging, storage, and mixing areas <br />13.Machinery repair areas <br />14.Pipelines, power lines, gas lines <br />15.Oiled or formerly oiled roads <br />16.Mounted transformers - evidence of leakage <br />17.Any mining activity or mining residue: past, present, or future <br />18.Wastewater treatment equipment, septic system, sewage lagoons <br />□ <br /> <br />□ <br /> <br />□ <br /> <br />□ <br />□ <br /> <br /> <br />□ <br /> <br />□ <br /> <br />□ <br />□ <br />□ <br />□ <br /> <br />□ <br />□ <br />□ <br />□ <br /> <br /> <br />□ <br /> <br /> <br /> <br /> <br />□ <br /> <br />□ <br /> <br />□ <br />□ <br />□ <br /> <br /> <br /> <br /> <br /> <br /> <br />DocuSign Envelope ID: 480AFBD4-654C-48FA-9CB8-F7C8D7E98DB2