Level 1 Survey:
Contaminant Survey Checklist
of Proposed Real Estate Acquisitions
INSTRUCTIONS: Check for each category. Explain briefly where something other than "No," "None," or "Not Applicable" is checked. Discuss whether a Level II or II Survey will be recommended. Describe the distance if nearby is checked and whether there is a known potential pathway for contamination on site. Attach a legal description of the real estate property covered by this survey.
A. Background Information
Bureau Name LL - Former
Site Name FORMER PROPERTY County State MINNESOTA
Date of Survey
B. Site Inspection Screen: On-site and nearby
ONSITE NEARBY NONE
1. Dumps, especially with drums, containers (Real labels if possible; do not open or handle! If no labels, note identifying characteristics)
2. Other debris: household, farm, industrial waste
3. Fills: possible cover for dumps
4. Unusual chemical orders
5. Storage tanks: petroleum products pesticides, etc.
6. Buildings: chemical storage, equipment repair, solvents
7. Structures -- evidence of asbestos sprayed fire proofing, acoustical plaster
8. Vegetation different from surrounding for no apparent reason, e.g. bare ground
9. "Sterile" or modified water bodies
10. Oil seeps, stained ground, discolored stream banks
11. Oil slicks on water, unusual colors on water
12. Spray operation base: air strip, equipment parking area
13. Machinery repair areas
14. Pipelines or major electrical equipment
15. Oiled or formerly oiled roads
16. Electric transmission lines: pole or pad mounted transformers which show evidence of leakage
17. Other (describe in Part E)
C. Record Searches (Coordinate with Realty title search, others as appropriate.)
1. Past uses which might indicate potential problems of site (CIRCLE any that are applicable.)
Manufacturing, service stations dry cleaning, air strip, pipelines, rail lines, facilities with large electrical transformers or pumping equipment, petroleum production, landfills, scrap metal, auto, or battery recycling, military, labs, wood preserving, other describe None
2. Nearby land uses, especially upstream or upgradient, or that might have had waste to dump at site (see list under Past Uses) Identify: None
3. Known contaminant sites in vicinity NPL, state sites, candidate sites (check with EPA; State EPA counterpart)
Yes No
4. Interviews on past use: owners, neighbors, County agents and any appropriate Federal authorities: Problems?
Yes No
5. Agricultural drainage history: surface, subsurface drains.
Yes No
D. In acquiring land from another Federal agency, that agency has notified the Department of the past or current presence of a hazardous substance under section 120(h) of CERCLA (Superfund).
Not applicable
Yes No
E. Has a non-Federal entity identified any hazardous materials problems on or near the site surveyed?
Yes No
F. A Level II study is recommended.
Yes No
A Level III study is recommended.
Yes No
Supplemental Information
Narrative description of site or potential contamination, justification for certification, photographs or maps illustrating potential contamination or location thereof, etc.
G. Certification
I hereby certify that to the best of my knowledge no contaminants are present on this real estate, and there are no obvious signs of any effects of contamination.
Signed Print Name
Date Title
On the basis of the information collected to complete this form it is possible to reasonably conclude that there is a potential for contaminants, or the effects of contaminants, to be present on this real estate.
Signed Print Name
Date Title
The surveyed real estate, or a portion thereof, contains contaminants. The owner of that real estate has/will cleanup the contaminants to bureau specifications, A Level II or Level III survey is not required.
Signed Print Name
Date Title
H. Approving Official
I concur with the above recommendation.
Signed Print Name
Date Title
EXCEPTION REVIEW CHECKLIST
This checklist may be used in determining whether an individual proposed action which is within a categorical exclusion (516 DM 2, Appendix 1 and 516 DM 6, Appendix 4) nevertheless requires the preparation of an EA.
1. Name and position of person completing this form:
2. Brief description of proposed action: FEE TO TRUST ACQUISITION - FORMER -
PROPERTY DESCRIBED AS: LL-
3. Answer the following questions "Yes" or "No."
Is the action one which may"
(a) Have significant adverse effects on public health and safety?
(b) Adversely affect such unique geographic characteristics as historic or cultural resources, park, recreation, or refuge lands, wilderness areas, wild or scenic rivers, sole or principal drinking water aquifers, prime farmlands, wetlands, floodplains, or ecologically significant or critical areas, including those listed on the Department's National Register of Natural Landmarks?
8 Have highly controversial environmental effects?
(d) Have highly uncertain environmental effects or involve unique or unknown environmental risks?
(e) Establish a precedent for future action or represent a decision in principle about a future consideration with significant environmental effects?
(f) Be related to other actions with individually insignificant but cumulatively significant environmental effects?
(g) Adversely affect properties listed or eligible for listing in the National Register of Historic Places?
(h) Affect a species listed or proposed to be listed on the List of Endangered or Threatened Species?
(I) Threaten to violate a Federal, State, local, or tribal law or requirements imposed for the protection of the environment or which require compliance with Executive Order 11988 (Floodplain Management), Executive Order 11990 (Protection of Wetlands), or the Fish and Wildlife Coordination Act?
If any question was answered "Yes", an EA is required.
Signature Date
CERTIFICATE OF INSPECTION AND POSSESSION
(Lands other than Federal Building Sites)
I, , Employee of the Leech Lake Tribal Council, hereby certify that on the day of , 20 , I made a personal examination and inspection of that certain tract or parcel of land legally described as: LL-Former situated in County, State of MINNESOTA, (proposed to be) acquired by the United States of America in trust for the Leech Lake Band of Chippewa Indians from .
1. That I am fully informed as to the boundaries, lines and corners of said tract; that after visual inspection, I found no evidence of work or labor having been performed or intent thereof for whatever purpose, and that I made careful inquiry of the above-names vendor (and of the occupants of said land) and ascertained that nothing had been done on or about said premises within the past six months and would entitle any person to a lien upon said premises for work or labor performed or materials furnished.
2. That I inquired of the above-names vendor (and of all occupants of said land) as to their rights of possession and the right of possession of any person or persons known to them and found no evidence or any information tending to show that any person had any rights whatever in said premises adverse to the right of the above-named vendor or the United States of America.
3. That I was informed by the above-named vendor (and by all other occupants) that to the best of their knowledge and belief; that there are no outstanding unrecorded encumbering documents affecting the title to said premises.
4. That to the best of my knowledge and belief, after diligent inquiry and visual inspection, that there is no evidence of water rights for any use; nor any ditches or canals under authority of the United States; nor any exploration or operations for the development of coal, oil, gas, or other minerals on said lands; and that there are no possessory rights existing by any third party under any reservation contained in any patent or patents heretofore issued by the United States for said land.
5. That said premises are now wholly unoccupied and vacant except for the occupancy of .
DATED THIS
DAY OF , 20 .
Inspector