TITLE V PROPERTY SURVEY
FEDERAL PROPERTY
INFORMATION CHECKLIST
(REV. 11/89)
INSTRUCTIONS: 1) Use this form.
2) Complete
all items below or the checklist will be returned for completion.
Date:
______________________ Property ID #
[____________________________]
(HUD will assign)
1. FEDERAL
LANDHOLDING AGENCY: Bureau:
___________________________________
2. PROPERTY
(name): ____________________________________________________________
(installation name, if applicable):
______________________________________________
3. ADDRESS
(street and number, or if none,
a brief description of how to locate
property)
4. GSA
INVENTORY CONTROL NO. (if available):
5.
PREVIOUSLY REPORTED TO HUD? o Yes o No
Determination by HUD (date:______________): o Suitable o Unsuitable
6. PROPERTY
DESCRIPTION:
o Building o
A. Current status: o Unutilized o Underutilized o Excess o Surplus
If excess or surplus,
GSA Disposal Control No.:
B. If underutilized, type of underutilization
(describe):
o Portion o Seasonal o Intermittent o Other (describe):
C.
Predominant surrounding land use:
D. Unusual physical features or impediments:
E. Legal constraints (right of entry, covenants,
permits, licenses, etc.):
F. Other (comments):
7. BUILDING
DESCRIPTION:
A. Age:
B. Structure type:
C. Size (usable square feet per floor):
D. Number of floors:
E. Current or most recent use (storage,
residential, office, etc.):
F. If currently occupied or leased, indicate:
i. Percentage of total space occupied or
otherwise in use: ______ percent.
ii. Expiration date(s) of any existing lease(s)
or renewal period(s):
F.
If currently vacant, indicate number of months vacant: ________
8. BUILDING
CONDITION: Meets or has the potential to
meet the following criteria:
MEETS POTENTIAL
Yes No Yes
No
A. Operating sanitary facilities o
o o o
B. Potable water o
o o o
C. Electric power o
o o o
D.
Indicate (if known) distance to
nearest utility hook-up(s):
E. Heating facilities adequate for climate o o o o
F. Structurally sound
i. Foundation o
o o o
ii. Floors o
o o o
iii. Roofs o
o o o
iv. Exterior walls o
o o o
v. Interior walls o
o o o
vi. Describe general condition or extent of
repairs needed
9. VACANT
LAND:
A. Size (acres, square footage):
B. Description of improvements (i.e. paved,
etc.):
C. Current or most recent use:
D. If occupied, indicate:
i. Percentage of total land area occupied or
otherwise in use: ______ percent.
ii. Expiration date of any existing lease or
renewal period:
10. VACANT
LAND CONDITION: Meets or has the potential to meet the following criteria:
MEETS POTENTIAL
Yes No Yes No
A. Operating sanitary facilities o
o o o
B. Potable water o
o o o
C. Electric power o
o o o
D.
Indicate (if known) distance to
nearest utility hook-up(s):
11. ACCESS:
A. Does this property have public access? o
Yes o No
If yes, how (road,
other):
If no, indicate:
i. Distance to the nearest road:
ii. Type of terrain:
iii. Miles to nearest town/city:
Accessible by public
transportation: o Yes
o No
Type of transportation:
B. Indicate any restrictions on access
(hours, etc.)
12. ENVIRONMENTAL
SUITABILITY:
A. Is the property subject to contamination by
toxic or hazardous materials or waste?
o Yes o No
Identify the
basis for determination (submit documents):
If yes, also
identify:
i.
Nature
of contaminants:
ii.
Location
of contaminants:
iii.
Extent
(percentage of building or number of acres affected) of contaminants:
iv.
Any
scheduled cleanup plans (include projected date of completion and estimate of
cost, if known:
B. Is an industrial/commercial Federal facility
handling flammable or explosive material (excluding underground storage)
located on the property or within 2,000 feet of its boundary (exclude
underground storage, gasoline stations, tank trucks, and any
above-ground container(s) with a capacity of 100 gallons or less of such
materials)?
o Yes
o No
If yes,
indicate:
i.
Number of acres (herein being determined for possible use by
the homeless)
located more than 2,000 feet
from such facility:
ii. Nature of the facility and material:
C: Is any portion of the property located within
an airport runway clear zone?
o Yes o No
If yes,
indicate the portion (percentage) of the property which is so located: ______ percent.
D. Is any portion of the property located within
a 100 year floodplain? (note that the fact that a Federal property is not
included in an existing floodplain map or study does not, by itself, justify a
"No" answer.)
o Yes
o No
E. Is the property impacted by any other
environmental condition which might jeopardize the safety of occupants of the
property (e.g., friable asbestos, PCBs, radon, periodic flooding)?
o Yes
o No
Indicate:
i.
Basis
for determination (submit document):
ii. Nature of condition:
iii. Extent of condition:
iv. Location of condition:
F. Are there any other known environmental
conditions which could affect or be impacted by the occupancy of the property
(e.g., endangered species, wild and scenic rivers, wetlands, historic properties,
storm water runoff; etc.)?
o Yes
o No o Undetermined
If yes, for
each:
i.
Describe
the environmental condition:
ii. Describe the potential impact:
iii. Basis for the determination (submit
document):
Title
V Property Survey - Federal Property Information Checklist (Rev. 11/89) Page 4
13.
SECURITY:
A. Is the property located in a secure facility
to which the general public is denied access?
o Yes o No
B. If the answer above is yes, can alternative
access be provided for the general public without compromising security
requirements?
o Yes
o No
Indicate method of providing access:
14. LIMITATIONS ON USE:
A. Are there now, or are there anticipated to be,
any other limitations not previously described on the use of this property to
assist the homeless for a period of one year or more?
o Yes
o No
If yes, describe the limitation:
B. Does the limitation currently exist?
o Yes
o No
If no, when will any limitation take
effect? ________________________
(date
of effect)
15. CHECKLIST CONTACT PERSON (name):
(title):
(phone
number):
(email):
(date
prepared):
o Yes
o No PHOTOS
(not required) are attached?
o Yes
o No Additional
amplifying information documents (not required) are attached?
ADDITIONAL
REMARKS (if any):
Title
V Property Survey - Federal Property Information Checklist (Rev. 11/89) Page 5