6200-03 Brownfields Area-Wide Planning Cooperative Agreement Rep

United States
ENVIRONMENTAL PROTECTION AGENCY
Washington, DC 20460

OMB Number No. 2050-0192
Expires XX/XX/XXXX

PROPERTY PROFILE FORM—Brownfields
Public reporting burden for this collection of information is estimated to average 1 hour 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 (Mandatory for All Cooperative Agreements)
1. Cooperative Agreement Recipient Name

2. Cooperative Agreement Number

(State/Tribe for

(Not applicable for TBAs):

Section 128(a) Cooperative Agreements; Requestor for TBAs):

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

Section 128(a) – State and Tribal Response
Multipurpose Grant

Assessment
Revolving Loan Fund
Cleanup

TBA (EPA Regions Only)

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

Petroleum

Hazardous Substance

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

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

Updated Form

Initial Form

PROPERTY BACKGROUND INFORMATION (Mandatory for All Cooperative Agreements)
6a. Property Name:
6b. Property Alias:
7. Property Owner:

Government (Tribal, State, Local)

Private
8b. City:

8a. Street Address:
8c. County:

8d. State:

9. Size (in acres):

8e. ZIP Code:
10. Parcel Number(s):

STATE & TRIBAL BROWNFIELDS/VOLUNTARY RESPONSE PROGRAM INFORMATION
11a. Is this property enrolled in a State or Tribal Voluntary Response Program?

Yes

No

11b. If yes, enter the enrollment date and ID number:
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)

12a. Latitude

12b. Longitude

(Use 00.000000 decimal degree

(Use -000.000000 decimal degree
format):

format):

EPA Form # 6200-03

PART II- ENVIRONMENTAL ACTIVITIES
ENVIRONMENTAL ASSESSMENT INFORMATION (Mandatory for Assessment Cooperative Agreements, Multipurpose Cooperative Agreements with assessments, State
and Tribal Property-Specific Assessments, and TBAs; and, if information is available, for Cleanup and RLF Cooperative Agreements)

Table A – Environmental Assessment Activity (If there are multiple assessments, please use a separate line for each assessment)
Source of Funding
Environmental Assessment Detail
(enter one source of funding per line; do not include funding received prior to the award of this EPA
Name of
Entity
Providing
Funds

CA

Start
Date

Activity Funded

Completion
Date

This
US EPA
CA

13a. Indicate Whether Cleanup is Necessary:

State/Tribal
(exclude
§128(a)
funds)

Other Federal

Yes

Local
Gov't

Private/
Other

Program
Income

Amount of Funding
Expended on this
Activity

Unknown

No

(If unknown is selected, update whether cleanup is necessary when a final determination is made)
13b. If Unknown, Select Reason:

Other:

CONTAMINANTS & MEDIA AFFECTED INFORMATION
Table B - Contaminants and Media Affected (check all that apply) Media can only be selected if a contaminant has been found and/or cleaned up:
Contaminants
Media
Class of Contaminant
Petroleum/Petroleum Products
Controlled Substances
Asbestos
PCBs
Pesticides
SVOCs
VOCs
Lead
Other Metals

Found

REC*

Media

Cleaned Up

Affected

Cleaned Up

Soil
Air
Surface Water
Ground Water
Drinking Water
Sediments
Building Materials
Indoor Air
No Media Affected

PAHs
Other Contaminants
No RECs
No Contaminants
Insufficient Information
*REC = Recognized Environmental Conditions. RECs are most commonly identified during a Phase I Assessment as areas of potential concern. For Controlled Recognized Environmental Conditions,
do NOT enter corresponding information for pre-existing Engineering & Institutional Controls.

ENVIRONMENTAL CLEANUP INFORMATION (Mandatory for Cleanup, Multipurpose, RLF, and State and Tribal Property-Specific Cooperative Agreements; and, if
information is available, for Assessment Cooperative Agreements and Targeted Brownfield Assessments)

14a. Cleanup Activity Start Date:

14b. Cleanup Activity Completion Date:

Yes

15a. Indicate whether Cleanup/Treatment Technology(ies) were implemented:

No

Unknown

15b. If Cleanup/Treatment Technology(ies) are required, indicate the category(ies) (check all that apply):

Excavation and disposal of soils

Removal of materials (tanks
and piping, etc.)

Extraction of contaminants (soil
vapor, free product,
groundwater, etc.)

Reduction of contaminants
through
Bioremediation/Phytoremediation

Cleanup of structures
(removal/abatement of
asbestsos/lead, PCB caulk,
other contaminated building
materials, etc...)

Additional Cleanup/Treatment Technology(ies) Information:

Address of Data Source (URL if available):
16a. Indicate whether Engineering Controls are required (Do not enter engineering
controls that are managing Controlled Recognized Environmental Conditions):

Yes

No

Unknown

16b. If Engineering Controls were required, indicate the category (check all that apply):

Cover Technologies (e.g., Capping)
Security (e.g., Guard,
Fences)

Immobilization Process (e.g.,
Encapsulation, In-Situ Solidification)

Engineered Barriers (e.g.,
Slurry Walls, Sheet)

Other

Additional Engineering Controls Information:

Address of Data Source (URL if available):
16c. Indicate whether Engineering Controls in place:
17. Acres Cleaned Up:

EPA Form # 6200-03

Yes

18. Number of Cleanup Jobs Leveraged:

No

Date:

PART II- ENVIRONMENTAL ACTIVITIES (continued)
19. 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):

Amount

Amount

Amount

Type
Section 128(a)
State/Tribal

Cost
Share

Multipurpose

Cost
Share

Cleanup

Program
Income

Cost
Share

RLF Loan
Date RLF loan
Signed

Interest Rate

Repayment Period

Cost
Share

RLF
RLF
Subgrant
Subgrant

Program
Income

Date RLF Subgrant
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)

Other Federal (Include
other EPA sources that
are NOT Brownfields
funding)

State/Tribal
(exclude §128(a)
funds)

Local
Gov't

Private/
Other

Name of Entity Providing Funds

Activity Funded

Amount of Funding Expended on
this Activity

INSTITUTIONAL CONTROLS INFORMATION (Mandatory for all cooperative agreement types)

Yes

20a. Indicate whether Institutional Controls are required:

No

Unknown

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

Proprietary Controls (e.g., easements, covenants)

Governmental Controls (e.g., zoning, building
codes, land use restriction )

Informational Devices (e.g., state registries,
deed notices)

Enforcement/Permit Tools (e.g., permits,
consent decrees)

Additional Institutional Controls Information:

Address of Data Source (URL if available):
20c. Indicate whether Institutional Controls in place:

No

Yes

Date:

21. Cleanup Completion Documentation. Select the type of documentation submitted to the EPA Project Officer.
*NFAs or EP Certification may not occur until after Institutional Controls are in place

No Further Action Letter Received

Date Received:

Letter/ Signed Report from an Qualified Professional

Date Received:

Other forms of documentation (subject to Project Officers approval). Please Describe:

PART III- ADDITIONAL PROPERTY INFORMATION
REDEVELOPMENT AND OTHER LEVERAGED ACCOMPLISHMENTS (Mandatory for Assessment, Cleanup, Multipurpose and RLF
Cooperative Agreements; and, if information is available, for State and Tribal Property-Specific activities and Targeted Brownfield Assessments)

22a. Redevelopment Start Date:

22b. 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)

Other Federal (Include
other EPA sources that
are NOT Brownfields
funding)

Local

State/Tribal Government

EPA Form # 6200-03

Private/Other

Name of Entity Providing
Funds

Activity Funded

Amount of Funding Expended on
this Activity

23. Number of Redevelopment Jobs Leveraged:
24. Redevelopment Land Use (Check all that apply). Indicate the acreage or square footage for each type of redevelopment on the
property.
Acres

or

Square Feet

Residential

Greenspace
Industrial
Commercial

ANECDOTAL PROPERTY INFORMATION (If information is available for all cooperative agreement types)
25. Property Highlights (Including Property Description, Past Uses, Past Ownership, Current Condition and Future Uses):

26. Predominant Past Use(s)

(Check all that apply. If multiple uses, indicate the acreage or square footage for each type of use)

Acres
Residential

Greenspace

Industrial
Commercial

EPA Form # 6200-03

or

Square Feet