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2. 
4. Environmental Site Assessment Information Application - $30 Application Fee

   Notice of City Response Time:  Following fee payment, the City of Portage will make every effort to respond to this request within five (5) business days after receiving it. However, be advised that the response may require a 10-business day extension. 

6. Contact Information
8. Name*
9. Email Address*
11. Company / Organization Name
13. Address*
15. City*
16. State*
17. Zip Code*
19. Phone Number*
20. Fax Number
22. Address of Subject Property
24. Address*
26. City*
27. State*
28. Zip Code*
30. Parcel Number (#####-###-#)
32. Information Requested (select all that apply)
34. Fire:

    1. Installation and/or removal of above-ground or underground storage tank(s)
    2. Known hazardous substance releases
    3. Active/outstanding fire code violations
35. Assessor:

    1. Current property record card(s)
    2. Historic property record card(s)
37. Planning & Zoning:

    1. Zoning code violations
    2. Site plans/diagrams
38. Building:

    1. Active/outstanding building violations
    2. Building permits
    3. Certificate(s) of Occupancy
40. Utilities:

    1. City sewer connection date
    2. City water connection date
41. Transportation:

    1. Planned roadwork which may impact the subject property
43. Other (please describe):
45. Date Rage for Information Requested*
    Date Rage for Information Requested Start Date

    —

    Date Rage for Information Requested End Date
47. Upload a File:
49. Delivery Method*

    1. Pick Up
    2. Mail

    1. Dropbox
    2. E-mail

    1. USB/CD (additional fees apply)
51. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
53. Requestor's Signature*
54. Date*
    Date
Leave This Blank:


56. 1. Receive an email copy of this form.
57. Email address

    This field is not part of the form submission.

58. Submit

* indicates a required field