Facility Survey Form

Field Area : Operating Unit :

Facility / Site Name/ ID/ Type : Date :
Current status : Active/ Inactive/ Iddle/ Remove Personel :
Coordinate : Survey/ Assessor
Year Installed / Remove : CPI persons :
FORM No. (If present)

Facility data (Describe the

process occur in the area)

Property boundary
(vicinity of the area) : North
South
West
East

A. HIS Impact
Remarks:
1 Access Road : No Access
Available Access: Distance to public road:
Good __________ m
Poor __________ m

Distance: Direction (N/ E/ S/ W from facility):

2 Adjacent Developed : Industrial __________ m
Land Use Residential __________ m
Others __________ m

3 Adjacent : Agriculture __________ m

Undeveloped Land Livestock __________ m

Use Forest __________ m

Peat __________ m
Vacant lot __________ m
 4 Sensitive receptors : Not Exist : Direction (N/ E/ S/ W from facility):
Exist : Distance from facility:
Canal __________ m
River __________ m
Drainage __________ m
Wetland __________ m
Other __________ m

if exist please measure and describe :

5 Suspected HIS : Not Exist :
Exist* :
*continue to HIS Findings
Describe:
6 Oil on surface water (canal) : (check with stick)
Odour :

7 Suspected impact : Not Exist :

other than HIS Exist* :
Hazardous substance :
Waste :
Water supply,
wastewater,
stormwater
PCB :
*continue to: Other Impact ODS :
questions Others issues :

Notes: Measurements from wells taken from well head. Measurements for larger facilities taken from boundary.

HIS Findings

Suspected area impacted Spot point

Findings No. Coordinate Remarks
(m2) (on location)
Sketch/ Map: Remarks:

B. FACILITY INFORMATION

Available
Material on site Remarks
(Y/N)
Concrete basin
Concrete building
Vessel tank
Steel structure
Piping (Galvanize or Stainless)
Piping (HDPE)
Piping (PVC)
Electricity - Transformer
Electricity cable
Electric pole
HDPE terpaulin
Machinery
Hydrocarbon container
Floor (pavement or concreted)
Drainage system
Others
C. OTHERS POTENTIAL IMPACT INFORMATION

1 Use and Storage of : Not Exist

Hazardous Substance Exist
Under Storage : Unit Volume (m3) Content & Year of Installment:
Tank

Condition Poor Double Tank UST

Good Secondary Containment
Best Leakage Occurred
If leakage occurred, specify volume or condition

Above Storage : Unit Volume (m3) Content & Year of Installment:

Tank

Condition Poor Concrete floor

Good Secondary Containment
Best Leakage Occurred
If leakage occurred, specify volume or condition

Warehouse : Unit Area (m2)

2 Waste Management
Sludge/Mud Solid trash Chemical Hazardous Material
Other:
Yes No Specify: Hazardous waste segregation
Vendor Onsite Other Hazardous waste treatment
Condition of hazardous storage
Poor Good Best (criteria: concrete location, secondary
containment, roofing, tidy

Yes No Specify: Domestic waste segregation

Condition of domestic waste bin
Poor Good Best (criteria: concrete location, secondary
containment, roofing, tidy

3 Water and Wastewater Management

Data Items

Domestic & Industrial wastewater

Domestic Industial Both
channel
Partly seperate Seperate Combine

River/canal Others Treatment Plant Wastewater discharge

m3/d m3/d m3/d Capacity

Availablity of wastewater treatment

YES NO
(WWTP) prior to discharge
m3/d as total Capacity
Canal/river Drainage Soil Water supply
Spill Leakage Other Overall condition of WWTP
 4 PCBS
Is there any PCB used at the area?
If yes, record : Brand Quantity Year

5 Ozone Depleting Substances (ODS)

Is there any ODS used at the area
If yes, observed type of ODS : Chiller/Refrigerant Split AC Others

Photos :

Photo Number Photo Description GPS Point Remarks