BLIS Online Site Submission Form

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Form Prepared By:
I. Site Information, Owner/Authorized Agent to contact:
Site Name: Contact/Authorized Agent:
Address: Title:
City: Relationship to Owner:
State: Zip: Contact Address:
Owner Name: City:
Tax Number: State: Zip:
Parcel Number: Phone:
Site is Owned Publicly: Fax:
OR Privately: Email:
II. Site Description

Lot Size (acres):

Number of Buildings:

Site is Currently:

Site is Currently Zoned:
Industrial Commercial Residential
Retail

Mixed Use

Other:
Pavement: No Yes, est. sq. ft.: Number of Parking Spaces:
Neighborhood: Metro Area/Region Name:
Brief Description of Site
(75 words or less):
III. Site History
Years the Site Operated:

Previous Uses:

Previous Ownerships: From: To: Owner: Use:
From: To: Owner: Use:
IV. Environmental Information
Phase I Completed: Yes No In Process, will be Completed:
Phase II Completed: Yes No In Process, will be Completed:
Site Investigation Completed: Yes No In Process, will be Completed:

Copies of reports available: No Yes, contact:

Contaminants Known or Suspected:
Remediation is in Progress: No Completed Yes, to be completed:

Remedial Action Plan: Submitted to DNR Approved by DNR Will be Submitted:

No Further Action Letter has been issued by DNR: Yes No
Site has Received DNR Closure: Yes No
Site Entered in Voluntary Party Cleanup Program: Yes No
Certificate of Completion has been issued by DNR: Yes No
Site is on the
following lists:
CERCLIS NPL RCRA PECFA Solid Waste
Haz. Spill UST LUST Landfill EPA Removal
Special Considerations:
Wetlands present Sensitive ecosystems or habitats present
Endangered species present Historic or archaeological sites present
Located w/in 100yr floodplain Located w/in 500yr floodplain
V. Community Involvement/Incentives Available
Level of Local Involvement: High Moderate Low Not yet involved
Describe Community's Goals and Concerns:
Owner/Agent Believes Site Eligible for Assistance from:

Local County State Federal Sources

in the following forms: Low Interest Loan Tax Rebate or Abatement Grant TIF Other:
VI. Tax and Deed Information
Current Assessed Value: $
Are Prop. Taxes Current: Yes No, Amount Owed: $
Date Taxes Last Paid:
Local Government will Forgive Back Taxes: Yes No Possibly
Any Liens or Judgements in Effect: Yes No
Any Easements in Effect: Yes No
Any Land Use/Deed Restrictions in Effect: Yes No
VII. Buildings
Building 1 Building 2 Building 3 Building 4
Name:
Total sq. ft.:
Year Built:
Last Renovation:
Ceiling Height:
Building Material:
Number of Cranes:
No. of Loading Docks:
No. of Drive-in Doors:
Sprinkler System: Yes No Yes No Yes No Yes No
Heating/Cooling Vents: Yes No Yes No Yes No Yes No
Plumbing in Place: Yes No Yes No Yes No Yes No
Lighting in Place: Yes No Yes No Yes No Yes No
VIII. Utilities
Public Water: On Site None Nearby, Distance:
Public Sewer: On Site None Nearby, Distance:
Electricity: On Site None Nearby, Distance:
Natural Gas: On Site None Nearby, Distance:
IX. Transportation Networks
Traffic Study Completed: Yes No
Road Access: Two Lane Four Lane Other, Describe:
Highway Access: Less than 1/2 mile More than 1/2 mile, Distance:
Port Access: On Site None Nearby, Distance:
Rail Access: On Site None Nearby, Distance:
Airport Access: On Site None Nearby, Distance:
Public Transportation Access: On Site None Nearby, Distance:

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This document was last revised: 15 August 2001
Wisconsin Department of Commerce