6200-03 Brownfields Property Profile Form

United States
ENVIRONMENTAL PROTECTION AGENCY
Washington, DC 20460

EPA Form: 6200-03
OMB Control No.: 2050-0192
Expiration Date: XX-XX-XXXX

PROPERTY PROFILE FORM—Brownfields
This collection of information is approved by OMB under the Paperwork Reduction Act, 44 U.S.C. 3501 et seq. (OMB Control No. 2050-0192). Responses to this collection of information are mandatory (2 CFR 200.328, 2 CFR 200.333, 2
CFR 200.335, 40 CFR 30-31). An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The public reporting and
recordkeeping burden for this collection of information is estimated to be 1 hour per response. Send comments on the Agency’s need for this information, the accuracy of the provided burden estimates and any suggested methods for
minimizing respondent burden to the Regulatory Support Division Director, U.S. Environmental Protection Agency (2821T), 1200 Pennsylvania Ave., NW, Washington, D.C. 20460. Include the OMB control number in any
correspondence. Do not send the completed form to this address.

PART I- PROPERTY INFORMATION

COOPERATIVE AGREEMENT RECIPIENT INFORMATION (Mandatory for All Cooperative Agreements)
1. Cooperative Agreement Recipient Name (State/Tribe for
Section 128(a) Cooperative Agreements; Requestor for TBAs):

2. Cooperative Agreement Number (Not applicable for TBAs):

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

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

Revolving Loan Fund
Cleanup

TBA (EPA Regions Only)

4. For Assessment, Cleanup, Multipurpose and Revolving Loan Fund cooperative agreements with announcement year
prior to 2020, what type of funding is being used at this property?
Hazardous Substance

Both

Petroleum

PROPERTY BACKGROUND INFORMATION (Mandatory for All Cooperative Agreements)
5a. Property Name:
5b. Property Alias:
6. Property Owner:
Government (Tribal, State, Local)

Private

7b. City:

7a. Street Address:
7c. County:

7d. State:

8. Size (in acres):

7e. ZIP Code:
9. Parcel Number(s):

STATE & TRIBAL BROWNFIELDS/VOLUNTARY RESPONSE PROGRAM INFORMATION
10a. Is this property enrolled in a State or Tribal Voluntary Response Program, or other applicable
oversight program?

Yes

10b. If yes, enter the Program/Agency Name and ID number (if applicable):
PROPERTY GEOGRAPHIC INFORMATION (EPA Brownfields Program, or its contractors, will
provide complete latitude/longitude & Cenus Tract information, if cooperative agreement recipients are unable)
11a. Latitude

(Use 00.000000 decimal degree format):

11c. Census Tract(s):

EPA Form # 6200-03

11b. Longitude

(Use -000.000000 decimal degree format):

No

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 Site Reuse Planning and Assessment Activities (If there are multiple assessments, please use a separate line for each assessment)
Source of Funding
(enter one source of funding per line; do not include funding received prior to the award of this
EPA CA

Environmental Assessment Detail

Start
Date

Activity

Completion
Date

12a. Indicate Whether Cleanup is Necessary:

This
US EPA
CA

Other Federal

Yes

State/Tribal
(exclude §128(a)
funds)

Local
Funding

No

Private/
Other

Post-Closeout Program
Income

Name of Entity
Providing Funds

Activity Funded

Amount of
Funding
Expended on
this Activity

Affected

Cleaned Up

Unknown

12b. If Unknown, Select Reason:
(If unknown is selected, update whether cleanup is necessary when a final determination is made)
Additional sampling required

Property marketability is not established

End use not yet determined

Awaiting determination from state agency

Reuse planning incomplete

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
Class of Contaminant
Petroleum/Petroleum Products
Controlled Substances
Asbestos
PCBs
Pesticides
SVOCs
VOCs
Lead
Other Metals

REC*

Found below
actionable level

Found above
actionable level

Media

Cleaned Up

Media

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

PAHs
No RECs
No Contaminants
Insufficient Information

CLIMATE ADAPTATION AND MITIGATION (Mandatory for All Cooperative Agreements)
13. Do any planning or assessment activities incorporate strategies to address climate change impacts? (Select all that apply):
Climate-focused Phase I and Phase II
ESAs

Updates to floodplain, coastal and
wetland, and/or hazard mitigation plans

Adoption of climate-conscious
building codes

Evaluate reuse options that are
climate conscious

Other

Identify potential risk factors and
infrastructure or utility vulnerabilities

N/A: This property does not incorporate planning or assessment activities to address climate change impacts

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)

14b. Cleanup Activity Completion Date:

14a. Cleanup Activity Start Date:
15a. Indicate whether Cleanup/Treatment Technology(ies) were implemented:

Yes

No

Unknown

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

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

Removal of materials (tanks and
piping, etc.)

Reduction of contaminants through
Bioremediation/Phytoremediation

Additional Cleanup/Treatment Technology(ies) Information:

Address of Data Source (URL if available):

EPA Form # 6200-03

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

PART II- ENVIRONMENTAL ACTIVITIES (continued)
16a. Indicate whether Engineering Controls are required (Do not enter
Engineering Controls that are managing Controlled Recognized Environmental
Conditions):

Unknown

No

Yes

16b. If Engineering Controls were required, indicate the category (check all that apply):
Engineered Barriers (e.g., Slurry
Walls, Sheet)

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

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

Other

Additional Engineering Controls Information:

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

Yes

Date:

No

17. Acres Cleaned Up:

18. Number of Cleanup Jobs Leveraged

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
Cost
Type
Share
Section 128(a)
State/Tribal
Multipurpose

Cost
Share

Cleanup

Cost
Share

RLF Loan

Cost
Share

Date RLF Loan
Signed

Program
Income

Anticipated Repayment
Start Date

Anticipated Repayment End
Date

Loan Discount

Loan Discount Info

Interest Rate

Cost
Share

RLF Subgrant

Program
Income

Date RLF Subgrant Signed

DIRECT CLEANUP INFORMATION (for Post-Closeout RLFs)
20. Total Direct Cleanup Program Income Amount:
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 State/Tribal
(exclude
sources that are NOT
Brownfields funding)
§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)
21a. Indicate whether Institutional Controls are required:

Yes

Unknown

No

21b. If Institutional Controls were required, indicate the category (check all that apply):
Proprietary Controls (e.g., easements, covenants)

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

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

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

Additional Institutional Controls Information:

Address of Data Source (URL if available):
21c. Indicate whether Institutional Controls are in place:

Date:

22. 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 a Qualified Professional

Date Received:

Other forms of documentation (subject to Project Officer approval). Please describe:

Date Received:

EPA Form # 6200-03

23. Do any demolition or cleanup activities incorporate strategies to address climate change impacts? (Select all that apply):
Reduce water use and impacts to water
sources

Reduce energy use and emissions
Sustainable land management practices

Reduce waste and manage materials
sustainably

Other

N/A: This property does not incorporate demolition or cleanup activities to address climate change impacts

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)

24a. Redevelopment Start Date:

24b. 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)

State/Tribal

Local Funding

Name of Entity Providing
Funds

Private/Other

Activity Funded

Amount of Funding Expended on this
Activity

25. Number of Redevelopment Jobs Leveraged:
26. 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

27. Do any redevelopment activities incorporate strategies to address climate change impacts? (Select all that apply):
Install green infrastructure

Incorporate renewable energy
development

Incorporate and encourage multi-modal
transit opportunities in redevelopment
activities

Other

Incorporate green building techniques.

N/A: This property does not incorporate redevelopment activities to address climate change impacts

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

29. 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