Tab_5-25

United States
ENVIRONMENTAL PROTECTION AGENCY
Washington, DC 20460

EPA Form: 560F22291
OMB Control No.: 2050-0192
Exp. Date: XX-XX-XXXX

GRANTEE REPORTED TECHNICAL ASSISTANCE TO BROWNFIELDS PROFILE FORM
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 3.66 hours 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.

TAB PROVIDER INFORMATION (mandatory for all TABs)
1. TAB Cooperative Agreement Number:

2. TAB Provider Name:
Yes

3. Is this funding from the Bipartisan Infrastructure Law (BIL) allocation?

No

PART I- COMMUNITY SPECIFIC INFORMATION (mandatory for all Community Specific TABs)
COMMUNITY INFORMATION
4. Community Name:
5. Community Type:
State

Tribe

County

Local Government

Regional Council

Redevelopment Agency

Non-Profit

University

Other
Yes

6. Has this community received any type of funding from the brownfields program in the past 9 years?
GENERAL COMMUNITY LOCATION INFORMATION
7a. Street Address (if applicable):
7b. ZIP code:

7c. City:

7d. State:

7e. County

8. Census Tract(s):
TECHNICAL ASSISTANCE PROVIDED
9. What activity was performed in the community?
Grant Application Prep/Review

Site Identification

Research/Education

Document Review/Assistance

Evaluation of Redevelopment Options

Training Facilitation

General Inquiries/Referral/Resource
Dissemination

Affiliation Event Planning/Participation

Other

10a. What is the relevant location of this activity?
Community-wide

Different than Community Address

Not Applicable

10b. If Different than General Community location, enter the information below:
Street Address (if applicable):
City:

State:

County:

ZIP Code:

11a. Latitude:

11b. Longitude:

12. Census Tract(s):
13. What is the relevant date(s) of this activity:

No

14. How does this project address changing climate conditions? (Select all that apply):
N/A: This project does not address changing climate conditions
Climate Risk Identification

Green Infrastructure and/or Green
Building Techniques

Sustainable Land
Management Practices

Use of Renewable Energy

Incorporate and encourage multi-modal
transit opportunities in redevelopment
activities

Other

PART II- MULTI-COMMUNITY TECHNICAL ASSISTANCE FORM
TRAINING/WORKSHOP/EVENT INFORMATION (mandatory for all Multi-Community TABs)
15. Training/Workshop/Event Name:
16. Description of Training/Workshop/Event:

TRAINING/WORKSHOP LOGISTICS
17. Role of the TAB provider in this Training/Workshop/Event:
Presenter/Trainer

Host/Organizer

18. How was the Training/Workshop/Event conducted?:

Virtual

19a. City

19b. State:

20a. Start Date:

20b. End Date:

Hybrid

TRAINING/WORKSHOP/EVENT ATTENDEES
21. Number of Training/Workshop/Event Attendees:
22. Number of Training/Workshop/Event Attendees that gained capacity
in at least one Brownfields related subject:
BROWNFIELDS PUBLICATION INFORMATION (mandatory for Multi-community TABs)
23. Publication Name:
24. Description of Brownfields publication:

25. Publicly Available URL (if applicable):
26. Publication Date:
BROWNFIELDS TOOL DEVELOPMENT INFORMATION (mandatory for Multi-community TABs)
27. Brownfields Tool Name:
28. Description of Brownfields Tool:

29. Publicly Available URL (if applicable):
30a. Development Start Date:

30b. Development End Date:

In-person