BPA F 5472.03e Temporary Land-Use Assessment Questionnaire

CUI
BPA F 5472.03e
(09-2023)
Pg. 1 of 3

U.S. DEPARTMENT OF ENERGY – BONNEVILLE POWER ADMINISTRATION (BPA)

TEMPORARY LAND USE ASSESSMENT OWNER QUESTIONNAIRE

OMB Control Number
1910-5190
Expires: XX/XX/XXXX

To be filled out by Requestor (BPA or Contractor) Prior to Providing Form to Landowner
Name:

Company:

Phone Number:

Email:

BPA Project Name:

BPA Contact:

Note: If the completed form is returned to the requestor, it is the requestor’s responsibility to send a copy to BPA Environmental
as indicated below. When complete, save as a PDF and email to owner or representative.
Owner or Site Manager Directions
Please answer the following questions to the best of your ability and initial at the bottom of each page. Provide the completed
Questionnaire to the BPA environmental office by either mail, email, or select “Submit” from the bottom of the second page.
Mailing address: Bonneville Power Administration, Attn: EP-Environmental Lead, PO Box 3621, Portland, OR 97208. Email signed
PDF copy or photo of questionnaire to: [email protected].
Where appropriate, include copies of reports, citations, permits, etc. For questions for which a “Yes” response is given, or for
those which otherwise need further explanation, please use the space provided on page 3 of the questionnaire or additional
pages as needed.
Site Address:
Property Owner:

Representatives
Name (if different)

Phone Number:

Years of Ownership:

Current Use of
Property:
Property is defined to include all areas within the proposed easement or agreement boundaries.
1.

Are there currently or have there been previously any damaged or discarded
automotive or industrial batteries, pesticides, paints, or other chemicals stored on
or used at the property?

Unknown

No

Yes

2.

Are there currently or have there been previously, any industrial drums (typically 5 55 gallon) or sacks of chemicals stored on or used at the property?

Unknown

No

Yes

Unknown

No

Yes

Unknown

No

Yes

Unknown

No

Yes

3.
4.

5.

Has fill dirt been brought onto the property that originated from a known
contaminated site or that is of an unknown origin?
Are there currently or have there been previously, any pits, ponds, bio-swales, or
lagoons located on the property in connection with water treatment or storm water
collection?
Are there currently or have there been previously, any stained soil or signs of
stressed vegetation on the property (other than related to automotive oil drip or
other similar source)?

Owner Initials

Filled in by BPA →

CONTROLLED DISTRIBUTION
Access is restricted to those with a Lawful Government Purpose and must be protected and
marked when printed or distributed.
Controlled by:
Name/Agency/Org/Contact Info:
CUI Category: PRVCY Date:
File Code: PA-1300; Retention: Destroy no sooner than 20 years after the records are closed.

CUI
BPA F 5472.03e
(09-2023)
Pg. 2 of 3

U.S. DEPARTMENT OF ENERGY – BONNEVILLE POWER ADMINISTRATION (BPA)

OMB Control Number
1910-5190
Expires: XX/XX/XXXX

TEMPORARY LAND USE ASSESSMENT OWNER QUESTIONNAIRE

6.

Are there currently or have there been previously, any vent pipes, fill pipes or access ways indicating a
fill pipe protruding from the ground on the property or adjacent to any structure located on the
property?

No

Yes

7.

Have any hazardous substances or petroleum products, unidentified waste material, tires, automotive
or industrial batteries or any other waste materials been dumped above grade, buried and/or burned
on the property?

No

Yes

8.

Are there any oil-filled electrical equipment such as electrical transformers or capacitors?

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

9.
10.
11.
12.
13.
14.

Are you aware of the past or current existence of hazardous substances or petroleum products on the
property?
Do you have any knowledge of environmental liens or activity and use limitations, such as deed
restrictions or institutional controls on the property?
Do you have any knowledge of governmental notification relating to past or recurrent violations of
environmental laws with respect to the property or any facility located on the property?
Have there been any past releases of any hazardous substances or petroleum products on the
property?
Do you have any knowledge of any past, threatened, or pending lawsuits or administrative
proceedings concerning a release, threatened release, any hazardous substances or petroleum
products involving the property?
Are there currently or have there been previously any fruit orchards or agricultural
Unknown
activities on the property?

15.

Are there currently or have there been previously any waste burning or chemical
treatment activities (i.e. pentachlorophenol dipping for fence posts)?

Unknown

No

Yes

16.

Are there currently or have there been previously any firearms target shooting
areas on or immediately adjacent to the property?

Unknown

No

Yes

17.

Please indicate with a check if you are aware of any of the following documents pertaining to the subject property:
Prior environmental site assessment reports
Environmental compliance audit reports
Environmental permits (i.e. solid waste disposal permits, hazardous waste disposal permits, wastewater permits,
discharge permits)
Registration for above or underground storage tanks
Registrations for underground injection systems
Notices or other correspondence from government agencies relating to past or current violations of environmental
laws or relating to environmental liens encumbering the property
Hazardous waste generator reports

Comments related to question 17

Owner Initials
File Code: PA-1300; Retention: Destroy no sooner than 20 years after the records are closed.

CUI
BPA F 5472.03e
(09-2023)
Pg. 3 of 3

U.S. DEPARTMENT OF ENERGY – BONNEVILLE POWER ADMINISTRATION (BPA)

TEMPORARY LAND USE ASSESSMENT OWNER QUESTIONNAIRE

OMB Control Number
1910-5190
Expires: XX/XX/XXXX

For any questions above with a “Yes” response, or which otherwise require additional explanation, please provide details.
Use additional pages if needed.

The undersigned represents that to the best of his/her knowledge the responses, statements and facts given in this
questionnaire are true and correct and no material facts have been suppressed or misstated.
Name:

Date:

Signature:

Affiliation with the property
Privacy Act Statement:
Authority: 42 USC § 7101
Purpose: BPA will use this information to assess potential environmental liability.
Routine Uses: This information is authorized to be maintained in Privacy Act system of records DOE-24: Land Records System.
Other routine uses for which this information may be disclosed are listed in the Privacy Act system of records notice for DOE-24,
which is published in the Federal Register.
Disclosure: Voluntary; however, failure to provide complete information may preclude BPA from acquiring land rights.
Paperwork Reduction Act Burden Statement:
This data is being collected by BPA to assess land for acquisition regarding environmental liabilities or issues associated with the
property. The data you supply will be used by BPA’s Pollution Prevention and Abatement organization to identify environmental
liability associated with acquiring land rights for transmission projects. Public reporting burden for this collection of information is
estimated to average .5 hours per response, including the time for reviewing instructions, searching existing data sources,
gathering and maintaining that data needed, and completing and reviewing the collection of information.
Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for
reducing this burden, to Office of the Chief Information Officer, Enterprise Policy Development & Implementation Office, IM-22,
Paperwork Reduction Project (OMB control number 1910-5190), U.S. Department of Energy, 1000 Independence Ave SW,
Washington, DC, 20585-1290; and to the Office of Management and Budget (OMB), OIRA, Paperwork Reduction Project (OMB
control number 1910-5190), Washington, DC 20503.
Notwithstanding any other provision of the law, no person is required to respond to, nor shall any person be subject to a penalty
for failure to comply with a collection of information subject to the requirements of the Paperwork Reduction Act unless that
collection of information displays a currently valid OMB control number.
The Paperwork Reduction Act (PRA) of 1995 requires each Federal agency to seek and obtain approval from the Office of
Management and Budget (OMB) before undertaking a collection of information directed to 10 or more persons of the general
public, including persons involved in or supporting the operations of Government-owned, contractor-operated facilities.
Submission of this data is voluntary.

SUBMIT

File Code: PA-1300; Retention: Destroy no sooner than 20 years after the records are closed.