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SWRPC Brownfields Site Nomination Form
This form is to nominate a potential or known brownfields site in the southwest region of New Hampshire for the Southwest Region Planning Commission's Brownfields Assessment Program.
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* Indicates required question
Site Information
Site Name
*
Your answer
Site Street Address
*
Your answer
Town / City
*
Your answer
Tax Map & Lot Number
*
Your answer
Property Size (Acres)
*
Your answer
Site History & Current Uses
How was the site last acquired (or how do you expect it will be acquired)?
*
Check one
Negotiated Purchase
Foreclosure
Donation
Eminent Domain
Purchased Outright
Other (please explain below)
Required
If other, please explain:
Your answer
What date was the site acquired (if applicable)?
MM
/
DD
/
YYYY
What are the site’s former and current uses?
*
Your answer
Are there structure(s) on the property?
*
Yes
No
Required
If yes, please describe:
Your answer
Are the building(s) occupied?
*
Yes
No
Required
If yes, partially or fully?
Partially occupied
Fully occupied
If the buildings are unoccupied or partially occupied, please explain why:
Your answer
Is the site known to be contaminated?
*
Yes
No
Required
If no, please explain why you are requesting Brownfields Assessment services, including a description of potential contamination.
Your answer
If yes, is the nature of the site contamination known?
Yes
No
If yes, please describe the nature of the contamination:
Your answer
Have studies been conducted to identify or assess contamination?
*
Yes
No
Required
If yes, please explain (if you wish to include findings/reports, please send to SWRPC staff via email or mail):
Your answer
Future Site Plans
Are there plans for expansion, redevelopment or reuse of the property?
*
Yes
No
Required
If yes, please explain:
Your answer
Are there any other issues relevant to this property that should be considered during the nomination process? (e.g. back taxes, tax liens, foreclosure, abandoned by owner, or other legal issues):
*
Yes
No
Required
If yes, please explain:
Your answer
Property Owner Information
Name
*
Your answer
Mailing Address
*
Your answer
Phone
*
Your answer
Email
Your answer
Nomination Submitted By:
Name or Office
*
Your answer
Date Nomination Submitted
*
MM
/
DD
/
YYYY
Mailing Address
*
Your answer
Phone
*
Your answer
Email
*
Your answer
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