State, Local, Tribal Government Reporting

United States
ENVIRONMENTAL PROTECTION AGENCY
Washington, DC 20460

EPA Form: 560F22290
OMB Control No.: 2050-0192
Expiration Date: XX-XX-XXX

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 1.33 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.

TECHNICAL ASSISTANCE INFORMATION (mandatory for all TAs)
1. Technical Assistance Contractor Name:

2. Lead Subcontractor Name:
No

Yes

3. Is this funding from the Bipartisan Infrastructure Law (BIL) allocation?
4. What type of Technical Assistance funding is being offered to this community?
Land Revitalization

Site Visioning/Market Analysis

Funding and Financing

5a. EPA Headquarters POC name:

EPA POC Information (mandatory for all TAs)
5b. EPA Headquarters POC email:

6a. EPA Regional POC name:

6b. EPA Regional POC email:

TECHNICAL ASSISTANCE RECIPIENT INFORMATION (mandatory for all TAs)
7. Technical Assistance Recipient Name:
8. Project Name:
9. Technical Assistance Recipient Type:
State

Regional Council

Academic/University

Non-Profit

Tribe

Local Government

Redevelopment Agency

Other

10a. Project Start Date:

10b. Project End Date:
PROJECT LOCATION INFORMATION (mandatory for all TAs)

11a. Street Address:
11b. City:

11c. County:

11d. State:

11e. ZIP Code:

12. Size (in acres):

13. Census Tract(s):
PROJECT BUDGET INFORMATION (mandatory for all TAs)

14a. Approved Budget:

15a. Cost Incurred:

Date: _____________

15b. Cost Incurred Start Date:

14b. Budget Increase:

15c. Cost Incurred End Date:

16. Balance Remaining:

Date: _____________
LAND REVITILIZATION TECHNICAL ASSISTANCE (mandatory for Land Revitalization TAs)
17. Has this community received Brownfields funding in the past 9 years?

Yes

No

PROJECT BACKGROUND INFORMATION (mandatory for all TAs)
18. Challenge(s) of the Community:

19. Anticipated Deliverables:

TECHNICAL ASSISTANCE ACTIVITIES (mandatory for all Land Revitalization TAs)
20a. What activities were performed on this project?
Sustainable Practices

Green Infrastructure

Strategic Action Plan

Site Design

Site Reuse Assessment

Economic Analysis

Community Engagement

Other

Activity Start Date:

Activity End Date:
TECHNICAL ASSISTANCE ACTIVITIES (mandatory for all Site Visioning TAs)

20b. What activities were performed on this project?
Market Analysis

Economic Research

Site Prioritization

Site Reuse Design

Site Reuse Assessment

Infrastructure Analysis

Community Engagement

Other

Activity Start Date:

Activity End Date:

TECHNICAL ASSISTANCE ACTIVITIES (mandatory for all Funding and Financing TAs)
20c. What activities were performed on this project?
Funding Options Analysis

Preparation for Loan Application or Sale

Financial Tool Development

Funding Charrette

Stakeholder Engagement

Financial Feasibility Study

Funding Gap Analysis

Other

Activity Start Date:

Activity End Date:
ADDITIONAL TECHNICAL ASSISTANCE PROVIDED (mandatory for all TAs)

21. 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

Use of Renewable Energy

Incorporate and encourage multi-modal transit
opportunities in redevelopment activities

22. Contractor Engagement with Community Benefiting from Technical Assistance:
Engagement Type
Kickoff Meeting
Scope of Work Finalized
Site Visit
Webinar
Deliverable Provided
Fact Sheet Provided

Date

Sustainable Land
Management Practices

Other

;

23. Final Project Deliverables Submitted:

24. Summary of Technical Assistance and Planned Next Steps:

25. Updates since Completion of Technical Assistance:

RELATED BROWNFIELD PROJECTS (mandatory for all TAs)
26. List any existing Brownfields Multi-purpose, Assessment, Cleanup or 128a
funding tied to this project: Enter the 8-digit Cooperative Agreement
number(s) associated to the funding:
27a. Has this project received any TBA funding?

Yes

27b. If yes, please select the state that funded this TBA:
28. Select any existing brownfields properties tied to this Technical Assistance
Project:

No