Environmental Questionnaire Form - Mineral Lease - 2000
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1NEW MEXICO STATE LAND OFFICE
MINERAL LEASE
ENVIRONMENTAL QUESTIONNAIRE
This questionnaire requests you to provide information concerning possible environmental risks associated with the
operations to be conducted on your lease site.
The State Land Office's request for the information specified in this questionnaire does not imply that the lease site is at
environmental risk from the presence or use of hazardous or toxic substances. Providing the requested information
does not relieve you of any liability or responsibility for actions which may be governable under any State or Federal
laws and/or regulations.
Providing this information may help you become aware of environmental concerns or risks associated with your
proposed operation. You may want to consult with an environmental engineer, consultant, or an attorney regarding
information provided in this form.
Name of Applicant: _____________________________________________________________________
Lease Number (if renewal): _______________________________________________________________
Address: ______________________________________________________________________________
Phone: _______________________________________________________________________________
Proposed operation (e.g. mining and crushing gravel, making asphalt cement):
______________________
__________________________________________________________________________________________
As part of your proposed operation, will you generate, use, store, transport, dispose of, or otherwise come in contact
with toxic and/or hazardous materials, and/or hydrocarbons? YES ______
NO _________
If Yes, please list the substances, the associated quantities and planned methods of disposal on a separate sheet of paper.
If the proposed operations involve any storage tanks, either above or below ground, please provide the following
information for each tank: (use a separate sheet of paper if more than one tank)
1.
Location of tank:
_______________________________________________________________
2.
Substance to be stored in the tank:
_________________________________________________
3.
Tank size in gallons:
____________________________________________________________
4.
Method of testing the tank for leaks:
________________________________________________
6.
Leak detection devices to be used:
_________________________________________________
Do you have knowledge of, or reason to suspect, any possible previous contamination of the lease site by any hazardous
or toxic materials or any hydrocarbons?
YES________
NO ___
If Yes, please provide detailed information on a separate sheet of paper.
I certify that due diligence has been exercised and proper inquiries made in completing this questionnaire, and that the
foregoing is true and correct to the best of my knowledge.
Dated this _____ day of _____________, 20
__________________________________
Lessee or Applicant
Rev. 1/27/00pcl
SLO-OGMD
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