6200-03 Property Profile Form - Brownfields

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Overview

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

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Sheet 1: Part I

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

Public reporting burden for this collection of information is estimated to average 1.5 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.

PART I- PROPERTY INFORMATION

COOPERATIVE AGREEMENT RECIPIENT INFORMATION

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):

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

4. For Assessment, Cleanup, and Revolving Loan Fund cooperative agreements, what type of funding is being used at this property?

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

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

PROPERTY BACKGROUND INFORMATION

6. Property Name:

6a. Property Alias

7a. Street Address:

7b. City:

7c. County:

7d. State:

7e. ZIP Code:

8. Size (in acres):

9. Parcel Number(s):

STATE & TRIBAL BROWNFIELDS/VOLUNTARY RESPONSE PROGRAM INFORMATION

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

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

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

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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 and Tribal Property-Specific Assessments, and TBAs; and, if information is 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

12a. Indicate Whether Cleanup is Necessary:

12b. If Unknown, Select Reason:

If Other

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

No End Use Known

Petroleum/Petroleum Products

Soil

Reuse Planning Not Complete

Controlled Substances

Air

Property is not Marketable

Asbestos

Surface Water

Additional Sampling Required

PCBs

Ground Water

Waiting Determination from State Agency

Pesticides

Drinking Water

Other

SVOCs

Sediments

VOCs

Building Materials

Lead

Indoor Air

Other Metals

No Media Affected

Unknown

PAHs

Other Contaminants

No Contaminants

Unknown

*REC = Recognized Environmental Conditions. For Controlled Recognized Environmental Conditions, enter applicable information into 19 and/or 20.

ENVIRONMENTAL CLEANUP INFORMATION (Mandatory for Cleanup and RLF Cooperative Agreements and State & Tribal Property-Specific Cleanups; and, if information is available, for Assessment Cooperative Agreements and TBAs)

13. Cleanup Activity Start Date:

14a. Cleanup Activity Completion Date:

14b. Cleanup Completion Documentation

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. For EPA Brownfields Funding used, Indicate the type and amount of funding (If any non-EPA Brownfields funding was used (including other types of EPA funding), fill out Table C):

Type

Amount

Type

Amount

Date RLF Subgrant Signed

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

Activity Funded

Amount of Funding Expended on this Activity

Other Federal

State/Tribal (exclude §128(a) funds)

Local Gov't

Private/ Other

Cost Share

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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; and, if information is 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

Activity Funded

Amount of Funding Expended on this Activity

Other Federal

State/Tribal

Local Gov't

Private/ Other

23. Number of Redevelopment Jobs Leveraged:

24. Planned and Actual Acreage (Check all that apply. For properties with multi-story buildings only, please indicate both the entire square footage and the square footage for each type of reuse (e.g., a three-story building with first floor commercial and remaining floors residential).

Planned

Actual

Acres

Sq. Ft.

Acres

Sq. Ft.

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Sheet 4: Part II cont.-IV

PART II- ENVIRONMENTAL ACTIVITIES (continued)

ANECDOTAL PROPERTY INFORMATION (If information is available for all cooperative agreement types)

25. Property Highlights:

PROPERTY PHOTOGRAPH INFORMATION

26. Indicate whether photographs are available:

27. Indicate whether video is available:

PART III- ADDITIONAL PROPERTY INFORMATION

PROPERTY HISTORY INFORMATION

28. Property Description / History / Past Ownership:

29. Predominant Past Use(s) (Check all that apply. For properties with multi-story buildings only, please indicate both entire square footage and the square footage for each type of past use (e.g., a three-story building with first floor commercial and remaining floors residential.)

Acres

Square Feet

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

30a. Ownership Entity:

30b.Current Owner:

31a. During the life of the cooperative agreement, did ownership change?

31b. If “yes,” did Superfund federal landowner liability protections factor into the ownership change?

PART IV- APPROVALS

32. Cooperative Agreement Recipient Project Manager

Name (please print):

Signature

Date:

33. US EPA Regional Representative

Name (please print):

Signature

Date: