Land-Use Survey Form

COMPANY CONTACT ADDRESS CITY/STATE/ZIP

RE: Land-use Survey Within 300 Feet of the following UST site: UST SITE NAME SITE ADDRESS CITY, STATE FACILITY ID #

Dear PROPERTY OWNER/TENANT:

CONSULTANT is conducting an environmental investigation on behalf of OWNER/OPERATOR NAME for the above referenced site to maintain compliance with the State Fire Marshal, Bureau of Underground Storage Tank Regulations (BUSTR). BUSTR requires that a survey be conducted on every property within 300 feet of the UST site referenced above to determine the current and potential future land use.

This letter was sent to you because your property is located within 300 feet of the UST site referenced above. Please answer the six questions below and return the form within 10 days to assist us in evaluating the area of the UST site. By returning this survey, you are helping us make a well- informed, environmentally responsible decision in your community. If you have any questions, please contact me by telephone at PHONE NUMBER.

Sincerely,

PREPARED BY PERSON'S TITLE

1. What is the property currently used as (Residential or Business)?: (if business, provide name & type of business) 2. How long has the property been used for the purpose described in item #1?: 3. What is the property currently zoned as?: 4. Has anybody ever lived on the property?: Yes No 5. Does anybody currently live on the property?: Yes No 6. Are there plans to allow anybody to live on the property?: Yes No

Comments: Signature of property owner/manager: Date: Enclosure: Self-Addressed Stamped Envelope