I. – Environmental assessment tabulated by the debtor
Name of the operator:
Company name:
Name of the insolvency administrator:
1. Identification of the site
City: Department:
Usual designation of the site:
Address:
Approximate area: m²
Activity:
Establishment subject to classified installations legislation:
A declaration
A authorisation
A Seveso directive
Nomenclature headings:
Attach a copy of the prefectoral decrees.
Attach a copy of environmental studies or safety documents already completed.
2. Site description
Site layout diagram, photograph(s):
| NAME | TYPE (1) | STATUS (2) | DIMENSION | PUBLIC ACCESS (3) | |
|---|---|---|---|---|---|
| (1) Manufacturing workshop, maintenance workshop, administrative building, energy production facilities (coal, gas..), utilities production (water, air, steam…), analysis laboratories, storage workshops, effluent treatment… (2) In relation to the potential risks: Degraded: Yes/No. If yes, specify the level: F(aible), M(oyen), E(levé). (3) Easy/Easy. |
Hazardous (or potentially hazardous) products present on site:
| Place or building. |
|---|
| Type of product (4). |
| Solid or liquid. |
| Packaging (5). |
| Condition of packaging (6). |
| Quantity: kg or m³. |
| Special hazards (7). |
| (4) Refer to the information on the labels, otherwise indicate no label; classification according to standard labelling: T+: very toxic; T: toxic; Xn: harmful; Xi: irritant; O: oxidising. (5) Drums, containers, tubs, crates, skips, in bulk; specify sheltered or outside. (6) Open or closed, leaking, corroded, stale drums. (7) Toxic, flammable, explosive or radioactive material. |
3. Occupation of the site
Conditions of access to the site:
Unfenced site, or fence in poor condition
Fenced site
Supervised site
Populations present on the site:
No presence
Indications of intrusion or squatting
Regular presence of people
Specify which:
4. Site environment
Agricultural/forest area
Natural area
Industrial area
Commercial area
Housing area :
– urban
– peri-urban
– dispersed
Sensitive establishments: proximity to schools or places frequented by young children:
Yes/No – Distance: m
5. Potential pollution(s)
Soil:
Visual evidence of soil pollution:
Yes/No – Specify which:
Air:
Presence of odours: Yes/No
Presence of easily dispersible products (e.g. powders): Yes/No
Specify which ones:
Surface water:
Presence of a watercourse nearby:
Yes/No – Distance: m
Name of watercourse:
Location in potential flood zone: Yes/No
Groundwater:
Presence of wells on site or nearby:
Yes/No – Distance: m
Sensitive use of groundwater (eg. Sensitive use of groundwater (e.g. drinking water supply catchment, agricultural wells):
Yes/No – Nature:
Distance from nearest catchment:
6. Emergency measures already taken
Access restrictions to the site, certain buildings (fencing….)
Potential hazard signage
Removal of hazardous products/waste
Sheltering of hazardous products/waste
Filling of voids
Other/specify:
7. Other comments
II. – Environmental report drawn up by a technician
Name of operator:
Company name:
Name of receiver:
Name of technician who carried out the report (if applicable):
Date of visit (if applicable): –/–/–
1. Site identification
City: Department:
Usual designation of site:
Address:
Approximate area: m²
Activity:
Etablissement soumis à la législation installations classées:
A déclaration
A autorisation
A directive Seveso
Rubriques de la nomenclature :
Joindre une copie des arrêtés préfectoraux.
Enclose a copy of any environmental studies or safety documents already completed.
In an irregular situation (1)
Specify for what reasons:
(1) The priority is to check that the activities present on the site have indeed been the subject of a declaration or request for authorisation from the prefectural services as provided for in the regulations.
2. Site description
Site layout diagram, photograph(s):
Buildings: number :
| NAME | TYPE (1) | STATUS (2) | DIMENSION | PUBLIC ACCESS (3) |
|---|---|---|---|---|
| (1) Manufacturing workshop, maintenance workshop, administrative building, energy production facilities (coal, gas..), utilities production (water, air, steam…), analysis laboratories, storage and effluent treatment workshops…
(2) In relation to potential risks: Degraded: Yes/No. If yes, specify level: F(aible), M(oyen), E(raised). (3) Easy/difficult. |
Hazardous (or potentially hazardous) products present on site:
| Place or building. |
|---|
| Type of product (4). |
| Solid or liquid. |
| Packaging (5). |
| Condition of packaging (6). |
| Quantity: kg or m³. |
| Special risks (7). |
| (4) Report information on labels, failing which indicate no label; classification according to standard labelling: T+: very toxic; T: toxic; Xn: harmful; Xi: irritant; O: oxidising.
(5) Drums, containers, tubs, crates, skips, in bulk; specify sheltered or outside. (6) Open or closed, leaking, corroded, stale drums. (7) Toxic, flammable, explosive or radioactive material. |
3. Occupation of the site
Conditions of access to the site:
Unfenced site, or fence in poor condition
Fenced site
Supervised site
Populations present on the site:
No presence
Indications of intrusion or squatting
Regular presence of people
Specify which ones:
4. Site environment
Agricultural/forest area
Natural area
Industrial area
Commercial area
Housing area :
– urban
– peri-urban
– dispersed
Sensitive establishments: proximity to schools or places frequented by young children:
Yes/No – Distance: m
5. Potential pollution(s)
Soil:
Visual evidence of soil pollution:
Yes/No – Specify which:
Air:
Presence of odours: Yes/No
Presence of easily dispersible products (e.g. powders): Yes/No
Specify which ones:
Surface water:
Presence of a watercourse nearby:
Yes/No – Distance: m
Name of watercourse:
Location in potential flood zone: Yes/No
Groundwater:
Presence of wells on site or nearby:
Yes/No – Distance: m
Sensitive use of groundwater (eg. Sensitive use of groundwater (e.g. drinking water supply catchment, agricultural wells):
Yes/No – Nature:
Distance from nearest catchment: m
6. Emergency measures already taken
Access restrictions to the site, certain buildings (fencing…)
Potential hazard signage
Removal of hazardous products/waste
Sheltering of hazardous products/waste
Removal of PCB transformers
Removal of radioactive sources
Filling voids
Other/specify:
7. Emergency measures planned or to be taken
Timeframe
Access restrictions to the site, certain buildings (fencing…) ……
Potential hazard signage ……
Removal of hazardous products/waste ……
Sheltering of hazardous products/waste ……
Removal of PCB-containing transformers ……
Removal of radioactive sources ……
Filling of voids …..
Other/specify …..
8. Impact monitoring
Have analyses been carried out:
– on groundwater: Yes/No
– on surface water: Yes/No
– on soils: Yes/No
– on other environments: Yes/No
Has any impact been noted: Yes/No
If so, please specify:
9. Other comments
