Updated 2016 June 15
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The City of Calgary | P.O. Box 2100 Stn. M | Calgary, AB, Canada T2P 2M5 | calgary.ca
Site Address:
Legal Description:
The information provided in this disclosure statement will assist the Development, Land Use and
Subdivision Authorities in processing planning applications. The Authorities rely on the information
provided in this statement to assist in determining the potential for site contamination, which may have
been caused by current or historic activities.
You are responsible for the accuracy of the information provided in this statement. The questions
must be answered to the best of your knowledge based upon diligent inquiry and the thorough
inspection and review of all documents and other information pertaining to the subject property.
Please be aware that further site assessments may be required as part of the review of your
application.
1.
Are you aware of any environmental investigations (audits, assessments,
tests, surveys or studies) for this site?
If yes, please provide copy(s).
Yes No
2.
Are you aware of any environmental requirements associated with any
previous planning applications on this site?
(i.e. development permit, land use redesign or subdivision)
If yes please provided a brief description and the associated development
application number(s):
Yes No
3.
Has there been site remediation or a request for such on the site?
If yes, please provide a brief description:
Yes No
Application # ____________________
for office use only
Site Contamination Statement
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The City of Calgary | P.O. Box 2100 Stn. M | Calgary, AB, Canada T2P 2M5 | calgary.ca
4.
Are you aware of any regulatory actions, past or current, which have been
applied to this site?
Examples include (but are not limited to):
- Environmental Protection Orders
- Reclamation Orders or Certificates
- Control / Stop Orders, fines, tickets or prosecutions
- Violations of environmental statutes, regulations and bylaws
- Administrative penalties and warning letters
If yes, please describe and provide copies of relevant documents:
Yes No
5.
Have any permits been issued or are you currently operating under a license
or approval issued by federal or provincial authorities or the Calgary Fire
Department for activities which may impact the property?
(e.g. certificates of approval, storage tank regulations, plant operating permits)
If yes, please describe:
Yes No
6.
Has there been contact with Alberta Environment or Calgary Regional Health
Authority regarding possible contamination on the site?
If yes, please provided a brief description:
Yes No
NOTE: This form is to be signed by the titled owner(s) of the property or their authorized agents or consultants.
I, the owner, authorized agent, authorized consultant, state that, to the best of my
knowledge, the information provided in this statement is accurate, complete and is based on diligent
inquiry and thorough inspection and review of all the documents and other information reasonably
available pertaining to the subject property. I am not aware of any other information that may indicate
that the subject property is potentially contaminated.
FOIP DISCLAIMER: The personal information on this form is being collected
under the authority of The Freedom of Information and Protection of Privacy
(FOIP) Act, Section 33(c). It will be used to provide operating programs, account
services and to process payments received for said services. It may also be used
to conduct ongoing evaluations of services received from Planning, Development
& Assessment. Please send inquiries by mail to the FOIP Program Administrator,
Planning, Development & Assessment, PO Box 2100, Station M, Calgary, AB T2P
2M5 or contact us by phone at 311.
Date
Applicant Signature
Applicant Name (Please Print)
Company Name (Please Print)
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signature
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