Encl 9 PAS with Lessor Signature_EC_405-1-15.pdf

PRELIMINARY ASSESSMENT SCREENING (PAS)

(Reference - EC 405-1-12)

1. Name of Project:

2. Description of Property:

Address: City: State: Zip:

3. Type of Real Property Transaction: A. [ ] Permit [ ] Easement [ ] In-Lease

B. [ ] New [ ] Renewal

4. Duration of Transaction: Effective Date: Ending Date:

5. Does the proposed transaction meet all screening criteria listed in 32 CFR, Appendix B, Part 651 for categorical exclusion (CX)? If yes, state CX reference: Section II.b.5

Yes No

6. Parties Involved: Proponent:

COE District:

Others:

7. Property Use(s) (briefly describe):

Past:

Current:

Proposed:

8. Existing or potential restrictions on use of property:

9. Party responsible for any remediation:

10. This property is categorized as: [ ] Type I – Uncontaminated

[ ] Type II - (Possibly contaminated) [ ] Type III - (Known to be contaminated)

If Type I, state why, give references:

If Type II, proceed with Survey phase to determine presence of contamination or environmental disruption. If property is found to be uncontaminated, reclassify as Type I. State why above. Use additional sheet to document as necessary.

If Type III, proceed with further study phase as necessary or prudent. Attach this form to any necessary documentation.

11. Check the appropriate box: [ ] The survey phase of this study has identified little or no potential for environmental contamination or disruption from past, present, or proposed activities. Therefore, this is a Type I property.

[ ] Further phases of this study have led to the determination that this project involves a Type III property. See attached documentation.

Prepared By: Date:

Reviewed By: Date:

Lessor Signature:_______________________________________________________ Date:_________________

ENCLOSURE 12