The following information is for myself: Select One Yes No If "no", the relationship to the proposed applicant is: Proposed Applicant Name Relationship Date of Birth: Do you own a home near the Smith & Thompson toxic dump, located at 230-244 W. Ave. L9 Lancaster, California 93534? Select One Yes No Approximately how close is your home to the Smith & Thompson toxic dump? Do you work at or near the Smith & Thompson toxic dump? Select One Yes No Approximately how close is your work to the Smith & Thompson toxic dump? Within the last two years, have you, or a family member living with you experienced any of the following symptoms: Death Select One Yes No Miscarriage/deformities Select One Yes No Kidney failure Select One Yes No Shortness of breath Select One Yes No Unexplained Illness Select One Yes No Fatigue Select One Yes No Body aches and/or flu like symptoms Select One Yes No Excessive coughing Select One Yes No Rashes Select One Yes No Increased number of headaches Select One Yes No Other: Describe every illness or injury you believe may have been caused by your proximity to the Smith & Thompson toxic dump. When did you first notice the symptoms listed above? Have you seen a doctor for any of the symptoms listed above? Select One Yes No Describe what treatment, if any, you have received in connection with every illness or injury you believe may have been caused by your proximity to the Smith & Thompson toxic dump. Has any doctor ever told you that any such illness or injury is the result of exposure to toxins? Select One Yes No Do you know of any other person who has experienced symptoms similar to yours? Select One Yes No If “yes,” please describe. Do any such persons live or work within a 4 mile radius of the Smith & Thompson toxic dump? Select One Yes No Do you have any children that go to school within a 4 mile radius of the Smith & Thompson toxic dump? Select One Yes No Have your children complained of any of the symptoms listed above? Select One Yes No Have any of your children exhibited unusual behavior? Select One Yes No If “yes”, please describe. Do any such persons live or work within a 4 mile radius of the Smith & Thompson toxic dump? Select One Yes No Do you own or lease any property within a four mile radius of the Smith & Thompson toxic dump? Select One Yes No Please describe any such property (eg., home, office, vacant land) Do you own a business within a four mile radius of the Smith & Thompson toxic dump? Select One Yes No Do you have any insurance that you believe may cover any property damage, including stigma, nuisance and diminution in value, caused by your proximity to the contamination from the Smith & Thompson toxic dump? Select One Yes No Do you have any insurance that you believe may cover any business loss you may have suffered as a result of you proximity to the contamination from the Smith & Thompson toxic dump? Select One Yes No How did you hear about us?