6200-03 Property Profile Form

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Overview

Part I
Part II
Part II cont.
Part III-IV

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Sheet 1: Part I

United States ENVIRONMENTAL PROTECTION AGENCY Washington, DC 20460 PROPERTY PROFILE FORM—Brownfields

Address Matching- House Number

Address Matching- Block Face

Address Matching- Street Centerline

Address Matching- Nearest Intersection

Public reporting burden for this collection of information is estimated to average 1.50 hours per response, including the time for reviewing instructions, searching data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate, or any other aspect of this collection of information, including suggestions for reducing this burden, to the Environmental Protection Agency, Office of Environmental Information, Code 2822T, Washington, DC 20460 and to the Paperwork Reduction Project, Office of Management and Budget, Washington, DC 20503. DO NOT RETURN your form to either of these addresses. Send your completed form to the address provided by the issuing office.

Address Matching- Primary Name

Address Matching- Digitized

Address Matching- Other

Census Block- 1990 Centroid

Census Block/Group- 1990- Centroid

Census Block/Tract- 1900- Centroid

PART I- PROPERTY INFORMATION

Census- Other

GPS Carrier Phase Static Position

COOPERATIVE AGREEMENT RECIPIENT INFORMATION

GPS Phase Kinematic Position

GPS (Pseudo Range) Differential

1. Cooperative Agreement Recipient Name (State/Tribe for Section 128(a) Cooperative Agreements; requestor/contractor for TBAs):

2. Cooperative Agreement Number (contract number for TBAs):

GPS (Pseudo Range) Precise Position

GPS (Pseudo Range) Standard Position (SA Off)

GPS (Pseudo Range) Standard Position (SA On)

3. What type of cooperative agreement funding is being used for this property?

Interpolation- Map

Interpolation- Photo

Interpolation- Satellite

Interpolation- Other

Loran C

Public Land Survey Quarter Section

Public Land Survey Section

Classical Survey

Zip Code- Centroid

5a. Indicate if this form is the initial or Updated Form:

5b. If "Updated Form," what's the ACRES Property ID?

Global Positioning Method- Unspecified Parameters

GPS Code (Pesudo Range) Standard-Service Correction

Interpolation- Digital Map Source (TIGER)

PROPERTY BACKGROUND INFORMATION

SPOT Satellite

6. Property Name:

Multi-Spectral Scanner

7a. Street Address:

7b. City:

Thematic Mapper

7c. County:

7d. State:

7e. Zip code:

Public Land Survey Eight Section

8. Size (in acres):

9. Parcel Number(s):

Public Land Survey Sixteenth Section

Public Land Survey Footing

STATE & TRIBAL BROWNFIELDS/VOLUNTARY RESPONSE PROGRAM INFORMATION

Zip Code Plus 4

10. State & Tribal Program Enrollment (If the property is not enrolled in a state program, check Property Not Enrolled check box):

Date of Enrollment:

ID Number (if applicable):

PROPERTY GEOGRAPHIC INFORMATION (EPA Brownfields Program, or its contractors, will provide complete latitude/longitude information if cooperative agreement recipients are unable)

Entrance Point of a Facility or Station

11a. Latitude (use 00.000000 decimal degree format):

11b. Longitude (use -000.000000 decimal degree format):

11c. Horizontal Collection Method:

Center of a Facility or Station

Point where Substance Enters Facility/Monitoring Site

Facility/Monitoring Site Boundary Point

11d. Source Map Scale Number (Only if a map/photo was used):

11e. Reference Point (e.g., Center of Facility or Station):

Point where Substance is Processed, Treated, Settled or Stored

Point where Substance is Released

11f. Horizontal Reference Datum (Choose one):

Point where Substance is Monitored

Other Point

EPA Form 6200-03 (9-2006)

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Sheet 2: Part II

PART II- ENVIRONMENTAL ACTIVITIES

Phase I

Phase II

ENVIRONMENTAL ASSESSMENT INFORMATION (mandatory for Assessment Cooperative Agreements, State & Tribal Property-Specific Assessments, and TBAs; as available for Cleanup and RLF cooperative agreement recipients; CA = Cooperative Agreement)

Supplemental Assessment

Table A – Environmental Assessment Activity (If there are multiple assessments, please use a separate line for each assessment)

Cleanup Planning

Environmental Assessment Detail

Source of Funding (enter one source of funding per line; do not include funding received prior to the award of this EPA CA

Name of Entity Providing Funds

Amount of Funding Expended on this Activity

Activity

Start Date

Completion Date

This US EPA CA

Other Federal

State/Tribal (exclude §128(a) funds)

Local Gov't

Private/ Other

12. Indicate whether cleanup is required:

CONTAMINANTS & MEDIA AFFECTED INFORMATION (mandatory for all cooperative agreement types)

Table B - Contaminants and Media Affected (check all that apply):

Contaminants

Media

Class of Contaminant

REC*

Found

Cleaned Up

Media

Affected

Cleaned Up

Petroleum/Petroleum Products

Soil

Controlled Substances

Air

Asbestos

Surface Water

PCBs

Ground Water

VOCs

Drinking Water

Lead

Sediments

Other Metals

No Media Affected

Unknown

PAHs

Other Contaminants

No Contaminants

Unknown

*REC = Recognized Environmental Conditions

ENVIRONMENTAL CLEANUP INFORMATION (mandatory for Cleanup and RLF Cooperative Agreements and State & Tribal Property-Specific Cleanups; as available for Assessment Cooperative Agreements and TBAs)

13. Cleanup Activity Start Date:

14. Cleanup Activity Completion Date:

15. Acres Cleaned Up:

16. Date No Further Action/Cleanup Completion Document Issued (If the property was not enrolled in a state or tribal program, leave blank):

Date:

17. Number of Cleanup Jobs Leveraged:

18. If EPA Brownfields funding was used, indicate the type and amount (If any non-EPA funding was used, fill out Table C):

Type

Amount

Type

Amount

Date RLF Loan Signed

Table C - Environmental Cleanup Leveraged Funding Detail

Source of Funding (enter one source of funding per line; do not include funding received prior to the award of this EPA Cooperative Agreement)

Name of Entity Providing Funds

Amount of Funding Expended on this Activity

Other Federal

State/Tribal (exclude §128(a) funds)

Local Gov't

Private/ Other

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Sheet 3: Part II cont.

PART II- ENVIRONMENTAL ACTIVITIES (continued)

INSTITUTIONAL & ENGINEERING CONTROLS INFORMATION (mandatory for all cooperative agreement types)

19b. If Institutional Controls were required, indicate the category (check all that apply):

Additional Institutional Controls Information:

Address of Data Source (URL if available):

19c. Indicate whether Institutional Controls in place:

Date:

20a. Indicate whether Engineering Controls are required:

20b. If Engineering Controls were required, indicate the category (check all that apply):

Additional Engineering Controls Information:

Address of Data Source (URL if available):

20c. Indicate whether Engineering Controls in place:

Date:

REDEVELOPMENT AND OTHER LEVERAGED ACCOMPLISHMENTS (Mandatory for Assessment, Cleanup and RLF Cooperative Agreements; as available for State and Tribal Property Specific Activities and TBAs)

21. Redevelopment Start Date:

22. Redevelopment Completion Date:

Table D- Redevelopment Leveraged Funding Detail

Source of Funding (enter one source of funding per line; do not include funding received prior to the award of this EPA Cooperative Agreement)

Name of Entity Providing Funds

Amount of Funding Expended on this Activity

Other Federal

State/Tribal

Local Gov't

Private/ Other

23. Number of Redevelopment Jobs Leveraged:

24. Future Use and Estimated Acreage (check all that apply; For properties with multi-story buildings only, please indicate also the square footage for each type of reuse (e.g. a three story building with first floor commercial and remaining floors residential).

acres

sq. ft.

acres

sq. ft.

acres

sq. ft.

acres

sq. ft.

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Sheet 4: Part III-IV

PART II- ENVIRONMENTAL ACTIVITIES (continued)

ANECDOTAL PROPERTY INFORMATION (as available for all cooperative agreement types)

26. Property Highlights:

PROPERTY PHOTOGRAPH INFORMATION

27. Indicate whether photographs are available:

28. Indicate whether video is available:

PART III- ADDITIONAL PROPERTY INFORMATION

PROPERTY HISTORY INFORMATION

29. Property Description / History / Past Ownership:

30. Predominant Past Use(s) (check all that apply; For properties with multi-story buildings only, please indicate also the square footage for each type of reuse (e.g. a three story building with first floor commercial and remaining floors residential):

acres

sq. ft.

acres

sq. ft.

acres

sq. ft.

acres

sq. ft.

OWNERSHIP & SUPERFUND LIABILITY (Mandatory for Cleanup and RLF Cooperative Agreements)

31a. Ownership Entity:

31b.Current Owner:

32a. During the life of the cooperative agreement, did ownership change?

32b. If “yes,” did Superfund federal landowner liability protections factor into the ownership change?

PART IV- APPROVALS

33. Cooperative Agreement Recipient Project Manager

Name (please print):

Signature

Date:

34. US EPA Regional Representative

Name (please print):

Signature

Date: