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* indicates a required field

2. Site Name*
4. Site Address or Location
6. Tax Parcel Number
8. Current Owner (if known)
10. Former Owner(s) of Significance

    (e.g. the former manufacturer)

12. Is there KNOWN environmental contamination?

    1. Yes
    2. No
14. Please explain.
16. Is there existing or potential developer interest in this site and/or adjacent sites? *

    1. Yes
    2. No
18. Please explain
20. Please include any other information such as site survey, tax assessment information, or other records that help identify the site.
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21. 1. Receive an email copy of this form.
22. Email address

    This field is not part of the form submission.

23. Submit

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