BUREAU OF INDIAN AFFAIRS AND BUREAU OF INDIAN EDUCATION
Environmental and Disposal Liability
Location of Concern Notification Form
Date:
Name of person completing Form:
Title:
Region/Agency School/Law Enforcement Facility:
Address:
Address 2:
Legal description/Building # (if known):
Contact Phone Number(s):
Please describe the area of concern. Include as much detail as possible and pay special attention to providing information on
how to locate the area. Also provide names/phone numbers of others who are ware of the details of the location or incident.
Office use only
Date received by responsible Line Officer
Name and title of Line Officer
Signature Phone Number
Date received by responsible Line Officer
RES Signature
Date
For RES: Please sign, date, and fax a copy to the Line Officer and DECRM. (check one). Due Care was performed and the site _____ is
an EDL, _____is not an EDL, _____is an "other unfunded liability", _____ needs further testing. Attach documentation for support of
finding.
