Stephens Environmental Consulting, Inc.

•Environmental Consulting •Engineering
•Land Planning •Remediation
•Underground Storage Tank Removal and Closure
•RTK & Static GPS Surveys •Conventional Surveys

Thank you for your interest in the services of SECI. Please provide the information that you have available in the spaces provided below. Feel free to bypass those sections that do not apply.

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Your RPF/Purchase Order (P.O.) Number:

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Type of Service(s) Requested (check all that apply):

Surveying Engineering

Phase 1 Environmental Site Assessment Construction Remediation Management

Phase 2 ESA PCB/Transformer Sampling

Radon Testing Infiltrometer Tests

Transaction Screen Surveying

Drinking Water Testing Construction Review

LUST Investigation Air Monitoring

Wetland Delineation Ground Water Sampling

Services Water Resources/Appropriation Brownfield Evaluation

Wetland Mitigation Brownfield Redevelopment Feasibility Study

Other:

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Owner Information:

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Bill To:

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Property Location:

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Latitude:
Longitude:

Property Description: (complete as applicable)

Total Site Area (Acres):

Percentage Wooded:

Buildings as Percentage of Area:

Total Number of Buildings:

Approx. Total Open Area (Acres):

Approx. Age of Oldest Structure On Site:

Total Number of Underground Storage Tanks (USTs) & Aboveground Storage Tanks (ASTs):

Approx. Age of Oldest UST On Site:

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Surveying	Engineering
Phase 1 Environmental Site Assessment	Construction Remediation Management
Phase 2 ESA	PCB/Transformer Sampling
Radon Testing	Infiltrometer Tests
Transaction Screen	Surveying
Drinking Water Testing	Construction Review
LUST Investigation	Air Monitoring
Wetland Delineation	Ground Water Sampling
Services Water Resources/Appropriation	Brownfield Evaluation
Wetland Mitigation	Brownfield Redevelopment Feasibility Study
Other:

Owner:		Contact Name:
Address #1:		Company:
Address #2:		Title:
City:		Tel. (work):
State:		Tel. (home):
Zip:		Tel. (Fax):
Country:		E-mail:

Client Name:		Contact Name:
Address #1:		Company:
Address #2:		Title:
City:		Tel. (work):
State:		Tel. (home):
Zip:		Tel. (Fax):
Country:		E-mail:

Name:		County:
Address #1:		Tax Parcel No.:
Address #2:		ADC Map/Block #:
City:		Nearest Intersection:
State:		Zoning:
Zip:		Current Use:
Latitude:		Longitude:

Total Site Area (Acres):
Percentage Wooded:
Buildings as Percentage of Area:
Total Number of Buildings:
Approx. Total Open Area (Acres):
Approx. Age of Oldest Structure On Site:
Total Number of Underground Storage Tanks (USTs) & Aboveground Storage Tanks (ASTs):
Approx. Age of Oldest UST On Site: