SECTION I: CUSTOMER INFORMATION

Legal Entity Name:

DBA:

Mailing Address:

City:

State: Zip Code:

Telephone:

Cell Phone:

Fax:

Email Address:

First Name:

Last Name:

SECTION II: LOCATION INFORMATION

Location Address:

City:

State: Zip Code:

Is an Environmental Site Assessment available?
Yes
No

Indicate prior uses of property. Check all that apply:
Habitational
Office / Hotel
Retail
Warehouse / Light Industrial
Industrial
Vacant Land
Other Specify:

Indicate any of the following operations currently conducted at the property address:
Service Station
Dry Cleaners
Auto Service / Repair
Manufacturing / Assembly
Hazardous Waste Generator - is waste storage area in compliance with regulation

None of the above

Indicate any of the following uses at adjacent properties. Check all that apply
Habitational
Office / Hotel
Retail
Warehouse / Light Industrial
Industrial
Vacant Land
Other Specify:

Are there or have there ever been any underground storage tanks on the property?
No
Yes
If yes, indicate contents:

If "Yes", have tanks been closed in accordance with applicable regulations?
Yes
No

Are there any above ground storage tanks on the property?
Yes
No

If Yes, indicate contents and quantity for each tank:

If Yes, describe secondary containment in place. If none, so state.

Have there been any claims made against you during the past five years for cleanup or response action, “toxic tort” or other bodily injury, or property damage, resulting from the release of hazardous substances, hazardous waste, or other pollutant, from this location or other locations owned or operated by you, into the environment?
Yes
No

If Yes, briefly describe the claim(s) and their disposition:

At the time of the signing of this application, do you know any facts or circumstances which may reasonably be expected to result in a claim or claims being asserted against your company for environmental cleanup, or for bodily injury or property damage arising from the release of pollutants into the environment?
Yes
No

If Yes, briefly describe:

Have you in the last five years had any reportable releases or spills of hazardous substances, hazardous wastes, or any other pollutants as defined by applicable environmental statutes or regulations?
Yes
No

If Yes, provide details:

Have you in the last five years been prosecuted or are you currently being prosecuted for contravention of any standard or law relating to the release or threatened release of a hazardous substance, hazardous waste or other pollutant as defined by applicable environmental statutes or regulations?
Yes
No

If Yes, provide details:

If needed, please list Mortgagee / Additional Insured information.

Mortgagee / Additional Insured:

Mailing Address:

City:

State: Zip Code:

Do you have lease restrictions on the use of hazardous substances?
No
Yes

Do you acquire environmental indemnity from the tenant(s)?
No
Yes

SECTION III: CONSTRUCTION AND PHYSICAL DESCRIPTION

Total Number of Buildings:

Total Square Footage:

Total Number of Rentable Units, including outdoor spaces:

Is facility originally designed for Self-Storage use?
Yes
No

If “No”, provide original purpose:

Building Construction:

Exterior Wall Material: If metal indicate gauge:

Joisting: If metal indicate gauge:

Roof Material: If metal indicate gauge:

Age of roof: Condition of roof:

Interior Partitions: If metal indicate gauge:

Number of Stories:

Age of Oldest Building:

Is facility fully fenced?
Yes
No

Controlled Gate Access?
Yes
No

Type of gate access:

Surveillance Cameras?
Yes
No

Lighted at night?
Yes
No

Individual door alarms hardwired?
Yes
No

Rental office on site?
Yes
No

Does manager reside on premises?
Yes
No

Is any other business or service besides self-storage located on the premises?
Yes
No

If "yes" provide details:

Daily Inspections of property includes

Tenant identification requirements

National Self-Storage Association (SSA) Member?
Yes
No

State Self-Storage Association (SSA) Member?
Yes
No

Describe Maintenance program: