ROAD SALT & GROUNDWATER QUALITY QUESTIONNAIRE

PROPERTY/LOCATION INFO

STREET NAME: *

PROPERTY TYPE (Check All That Apply): *

Residential (House/Condo/Apt)

Commercial/Business

Industrial

WHERE DOES THE DRINKING WATER COME FROM? *

Connected to MVD Water

From a Well

Unsure

Other (enter info below)

WHERE DOES THE WASTE WATER GO? *

Connected to Public/Town Sewer

To a Septic System

Unsure

Other (enter info below)

WHO REMOVES SNOW & ICE AT THE PROPERTY? (Check All That Apply) *

Property Owner

Tenant

Maintenance Department

Property Manager/Mgmt. Company

A Snow/Ice/Plow Person/Company (Enter Info Below)

AMOUNT OF SALT USAGE? (Please choose the approx. amount of salt used PER YEAR for de-icing) *

0 - 10 lbs

11 - 50 lbs

51 - 100 lbs

Greater than 100 lbs

No Salt Used (enter info below)

LOCATIONS WITH WELL WATER - if Sodium & Chloride Level are known please enter info below:

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