Pilot Program Survey — AFFF Take-Back & Replace

Before you complete this brief survey, please conduct a visual inventory of your current AFFF supply.

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* 1. Fire Department Address

Fire Department Name

Address *

Address 2

City/Town *

ZIP/Postal Code *

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* 2. Fire Department County

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* 3. Please designate a primary point of contact at the fire department who we can reach out to regarding AFFF:

Name *

Role at the Fire Department

Email Address

Phone Number

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* 4. Is your fire department a volunteer fire department?

Yes

No

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* 5. Does your fire department currently have AFFF containing PFAS?

Yes

No

Not sure

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* 6. Is your fire department required to keep AFFF containing PFAS on-hand due to Federal Aviation Administration (FAA) or military regulations (Mil-Spec)?

Yes

No