VILLAGE ENVIRONMENTAL PLANNING SURVEY*

ADEC ver 1.0

Village of __________________________________________

There may be very serious problems with environmental pollution in our village.

We need your help in ranking, or prioritizing, the environmental problems listed below.

This survey form is designed to obtain your opinion and input, to develop our village environmental protection plan. This survey will help us address serious problems with solid waste, hazardous/toxic pollutants and other environmental problems in our village. Outlined below are environmental health problems or environmental issues that need to be addressed.

Each environmental issue listed below needs to be ranked as to how important you believe the issue is. "1" is the lowest ranking or priority, and "5" is the highest ranking or priority.

Each issue needs to have a value marked in the box as to how important you think the issue is.

1. (____) Hazardous materials and toxic waste cleanup in dump sites and other areas.

2. (____) Abandoned vehicles, boats and equipment in and around the village.

3. (____) Beach erosion.

4. (____) Village landfill (dumpsite)

5. (____) Construction materials on project sites that are left behind by contractors.

6. (____) Abandoned drums in and/or around the village.

7. (____) Raw sewage spills in the community and raw sewage disposed at the lagoon.

8. (____) Annual clean-up and green-up program.

9. (____) Indoor air pollution, such as secondhand cigarette smoke.

10. (____) Fuel oil contaminated soils in and/or around the village.

11. (____) Air pollution, dust or other air pollution problems caused by the generator, heavy equipment or vehicles in the village.

12. (____) Animal carcasses or fish carcasses left in or around village.

13. (____) Trash left in or around the village.

14. (____) Other environmental issues beyond village control, such as ozone depletion.

15. (____) Environmental pollution contaminating subsistence foods.

16. ( ) Old military sites cleanup.

Please use the space below for comments or if you feel that there are other environmental health issues you feel that need to be addressed.

This survey information is very important to us and we thank you for taking time to fill out this survey. Our goal is to make your community an environmentally safe place to live and raise families and your participation in this survey will greatly assist us in accomplishing that goal.

If you have any questions regarding this survey or any concerns please feel free to call at .

Signed by__________________________________

Date_______________________________________

* For more information, contact:

Bill Stokes, Rural Environmental Quality Specialist
State of Alaska
Department of Environmental Conservation
555 Cordova Street
Anchorage, AK 99501
Toll Free: 1-800-510-2332
Phone: (907) 269-7580
e-mail: bstokes@envircon.state.ak.us