Applicant Certification of Known Environmental Issues
Last Updated: April 2025
Instructions: It is not necessary at the time of initial application to have an Environmental Site Assessment (ESA); however, if an ESA of any type has been conducted, you are required to disclose all known environmental issues below. If awarded funding, an ESA and other applicable environmental submittals are required prior to loan commitment/ loan closing. 
Development Information
Development Name:      
Development Street Address:      
Development City, State ZIP Code:      
Year Building(s) Built (first occupied):      
Previous uses of the site:      
Source of this information:      
Known Environmental Issues
Section 1: Overview
Inquiry	Response	
Has a Phase I Environmental Study been completed?		
Date of Report	     	
Summarize any recognized environmental conditions.	     	
Section 2: Asbestos
Inquiry	Response	
Has an Asbestos Containing Materials (ACM) test been completed?		
Date of Report	     	
Comments	     	
Is there any friable asbestos within the subject project?		
Attach a copy of ACM test results, and/or attach a copy of an existing asbestos management plan, if applicable.		
Section 3: Lead Based Paint
Inquiry	Response	
If the proposal includes rehabilitation of an existing building, was it constructed prior to 1978?
If “Yes,” proceed with next lead-based paint (LBP) question.		
Is the building exempt from LBP requirements due to the proposed scope of work or population being served?
If “No” or “Unknown,” proceed with remaining LBP questions.		
Has a visual assessment been conducted by a qualified individual?		
If “Yes,” was any deteriorated paint identified?		
Will the proposed scope of work involve disturbing any painted surface?		
Has a lead hazard evaluation, including LBP inspection/risk assessment, been conducted?		
If “Yes,” was the presence of lead or lead hazards found within the subject property?		
If applicable, attach a copy of the lead hazard evaluation results.		
If applicable, attach a copy of an ongoing LBP Maintenance Plan or Lead-Free Building Certification.		
Comments	     	
Section 4: Mold
Inquiry	Response	
Is there visual evidence of mold growth on any interior surfaces, or are there any known leaks on the building envelope that might contribute to concealed water damage or mold?		
If “Yes,” explain where and identify any assessments completed.	     	
Comments	     	
Section 5: Other Hazards and Toxic Materials
Inquiry	Response	
Is the subject property adjacent to or located within ¼ mile of a Superfund, National Priority, CERCLIS, or CERCLA site, or within 3000 feet of a toxic or solid waste landfill?		
Comments	     	
Are there known methamphetamine (meth) manufacturing labs or evidence of former meth manufacturing labs within the subject property?		
If “Yes,” provide information.	     	
Comments	     	
Are there any underground or above-ground fuel storage tanks present on the subject property? Is the subject property located within 1 mile of any 100+ gallon above-ground tanks?		
If “Yes,” address the following: number of tanks, capacity, usage, location, age, date of last tank installation/removal and delivery system tightness test, and test results.	     	
Comments	     	
If there are unused tanks or tanks that were removed and there was a soil test done, attach a copy of the test.		
Is there a major roadway within 1,000 feet, a railroad within 3,000 feet, a civil airport within 2,500 feet, or a military airport within 15,000 feet of the subject property?		
If “Yes,” identify the roadway, railroad, and/or airport and the distance of each from the subject property.	     	
Comments	     	
Are the structures or proposed structures at least 10 feet from all gas line and power line easements?		
Comments	     	
Are there any wells on site?		
If “Yes,” address the following: the current usage, the location, and whether it has been capped under Minnesota Department of Health and local requirements (if well is unused).	     	
Comments	     	
Is any portion of the subject property near any power, television, or microwave tower(s)?		
If “Yes,” list the tower’s height is and the distance to the subject property.	Height:      
Distance:      	
Comments	     	
Is any portion of the subject property at or below the 100- or 500-year flood plain, or in a Floodway or Coastal High Hazard Area?		
Comments	     	
Is any portion of the subject property within 100 feet of a wetland?		
Comments	     	
If this is a new construction proposal, has there been any recent site preparation or other alteration to the site?		
If “Yes,” has the project been given clearance from the State Historical Preservation Office (SHPO) that it will not have a significant adverse impact on any known historic preservation in the immediate area?		
Comments	     	
If this is a new construction proposal, is the project’s county or air quality management district in nonattainment or maintenance status for any criteria pollutants according to the EPA Green Book?		
Comments	     	
Is any portion of the subject property located on prime farmland, unique farmland, or farmland of statewide importance according to the USDA?		
Comments	     	
Is any portion of the subject property within proximity to a National Wild and Scenic Rivers System (NWSRS) river according to the NWSRS or National Park Service?		
Comments	     	
Are any federally listed protected species or designated critical habitats present in the project area according to the US Fish and Wildlife Service (USFWS)?		
Comments	     	

Certification
I,      , hereby certify that the information set forth in this Applicant Certification of Known Environmental Issues, and in any supporting attachments (if applicable), is true, correct, and complete to the best of my knowledge and belief.
     
Name of Developer
     	     
Authorized Signatory Printed Name	Title
     	     
Authorized Signature	Date