Environmental QuestionnaireAnd Disclosure Statement

The purpose of this questionnaire is to provide information upon which ATB will rely in deciding whether or not to extend credit. Please respond to all questions. If unable to answer, please respond “unknown” or “not applicable”. Where space is inadequate to answer, please attach additional pages as needed.

1. / THE BUSINESS
Legal Name:
2. / REAL PROPERTY
2.1 Lands
Municipal address or location:
Present use of the Lands:
Previous uses of the Lands (if known, then provide associated dates):
Do you own the Lands? / Yes / No / (If “no”, then proceed to 2.2)
When did you acquire the Lands?
From whom did you acquire the Lands?
Legal description:
2.2 Buildings
Are there any Buildings on the Lands? / Yes / No / (If “no”, then proceed to 2.3)
Please provide particulars of any buildings on the Lands (i.e. description, dimensions, construction details, age etc.):
Do any of the Buildings contain any of the following: hazardous materials, flammable materials, explosives, acids, industrial chemicals, asbestos, urea formaldehyde foam insulation (UFFI), polychlorinated biphenyls (PCBs) or lead?
Yes / No / Unknown
Comments (If “no” is answered, then comments are not required and proceed to 2.3):
Has a survey been conducted to assess the type, amount, location and condition of these Building contents?
Yes / No / Unknown
Comments (If “yes” is answered, then attach the copy of any related written report):
2.3 Adjacent Properties
Is any adjacent property being, or ever been, used for industrial, manufacturing, refining or processing purposes including, without restriction, gasoline services, commercial printing or dry cleaning?
Yes / No / Unknown
Comments (not required if “no” is answered):
3. / SPECIFIC ENVIRONMENTAL CONCERNS
3.1 Product and Raw Materials
Nature of the product handled and list the major raw materials used (e.g. chemicals, metals, plants etc.):
Describe the types of liquid, or solid, wastes generated:
3.2 Waste Storage and Disposal Practices
Have any of the following ever been buried, dumped, stored, burned, emitted or otherwise disposed of involving the surface waters, Buildings, adjacent properties or Lands themselves?: (a) chemical or industrial waste, (b) oil/petroleum product waste, (c) bio-solids from waste water treatment plants, or (d) other waste material?
Yes / No / Unknown
Comments (If “no” is answered, then comments are not required and proceed to 3.3):
3.2.1 Air Contaminants
Does the Business emit air contaminants from vent stacks or sources other than heating, or air conditioning, systems?
Yes / No / Unknown
Comments (not required if “no” is answered):
3.2.2 Pipelines or Storage Tanks
Are, or were, any aboveground or underground pipelines or gasoline, diesel, motor oil or other storage tanks located on the Lands?
Yes / No / Unknown / If “no” is answered, then proceed to 3.2.3
Have the pipelines or storage tanks ever been tested for leakage and, if so, when?
Yes / No / Unknown
Comments (not required if “yes” is answered and date is given, provided a copy of the related report/test results is attached):
If pipelines, please indicate the product carried, diameter and approximate installation date:
If storage tanks, please list the number, capacities (litres or gallons), product stored, construction (e.g. steel, fiberglass etc.) and installation date (approximate, if unknown):
If storage tanks, are these registered with the local fire department and/or provincial Ministry of Environment or Labour (PTMAA) program in Alberta?
Yes / No / Unknown
Comments (not required if “yes” is answered, but provide a copy of any related registration letters):
If there are only aboveground storage tanks on the Lands, i.e. no underground storage tanks, then proceed to 3.2.3
Is there any cathodic protection (steel tanks only), overfill protection devices or secondary containment system associated with the underground storage tanks
Yes / No / Unknown
Comments (not required if “yes” is answered):
3.2.3 Floor Drains, Sumps, Dry Wells, Waste Water Ponds, Septic Beds or Septic Tanks
Are there, or were there previously, any floor drains, sumps, dry wells, waste water ponds, septic beds or septic tanks on the Lands?
Yes / No / Unknown
Comments (If “no” is answered, then comments are not required and proceed to 3.2.4):
Are the floor drains and/or sumps (as applicable) connected to the sanitary sewer system?
Yes / No / Unknown
Comments (not required if “no” is answered):
3.2.4 Water Wells
Are there, or were there previously, any water wells on the Lands?
Yes / No / Unknown
Comments (If “no” is answered, then comments are not required and proceed to 3.3):
Has water from the wells ever been submitted for quality analysis?
Yes / No / Unknown
Comments (If “yes” is answered, then attach a copy of the relevant laboratory analytical results):
3.3 Transportation of Hazardous or Dangerous Goods
Are hazardous, or dangerous, goods delivered to the Lands?
Yes / No / If “no”, proceed to 3.4.
Are suppliers licensed to transport such hazardous, or dangerous, goods according to current Transportation of Dangerous Goods regulations?
Yes / No / Unknown
Comments (not required if “yes” is answered):
3.4 Miscellaneous
Are there currently, or have there previously been, discarded on the Lands any automotive batteries or pesticides, paints, solvents or other chemicals stored in individual containers of greater than 5 gallon (19 litres) volume?
Yes / No / Unknown
Comments (not required if “no” is answered):
Other than as described above, how and where is product or raw materials stored?
Other than as described above, how does the Business dispose of its waste?
List all licenses and permits issued by provincial or municipal authorities related to discharges or emissions:
4. / GENERAL ENVIRONMENTAL CONCERNS
Has any material been placed on the Lands from a contaminated site or from an unknown origin?
Yes / No / Unknown
Comments (not required if “no” is answered):
Has there ever been a spill, or release, of petroleum products, PCBs, pesticides, solvents or other hazardous substances on the Lands?
Yes / No / Unknown
Comments (If “yes”, then attach the copy of any written report detailing remedial measures taken):
Is there any surface staining, distressed vegetation or unexplained subsidence on the Lands?
Yes / No / Unknown
Comments (not required if “no” is answered):
Are personnel who handle hazardous substances on the Lands trained in Workplace Hazardous Materials Information System (WHMIS)?
Yes / No / Unknown
Comments (not required if “yes” is answered):
Has the current, or previous, business occupying the Lands ever been issued a license to operate under the Alberta Clean Air Act, Clean Water Act or Alberta Environmental Protection and Enhancement Act?
Yes / No / Unknown
Comments: (not required if “no” is answered):
Has there ever been any control orders, stop orders, prosecutions or tickets issued by Alberta Environment to the current, or previous, business occupying the Lands?
Yes / No / Unknown
Comments (not required if “no” is answered):
Has an environmental investigation, audit or assessment ever been undertaken with respect to the Lands?
Yes / No / Unknown
Comments (If “yes”, then attach the copy of any related report):
Are there any previous, existing, pending or threatened actions or litigation by government or private parties involving environmental issues with the Lands?
Yes / No / Unknown
Comments (not required if “no” is answered):

Customer’s Signature

I (undersigned) represent and warrant that, to the best of my knowledge and after due inquiry and investigation, that the information contained herein is true and correct and that I have candidly disclosed to Alberta Treasury Branches (“ATB Financial”) all past and present environmental issues relating to these Lands.
Furthermore, I agree to immediately notify ATB Financial of any future environmental issues involving the Lands as they become known to me.
Insert individual Customer's name / Date
INSERT CORPORATE CUSTOMER'S NAME
Per: Insert name of corporate Customer's signing officer / Date
Insert title of corporate Customer's signing officer
And per: Insert name of corporate Customer's signing officer / Date
Insert title of corporate Customer's signing officer

Form 3001 (Rev. 10/09)®Registered trademark of Alberta Treasury Branches.Page 1 of 4