Non-Profit Reporting

OMB No. 2050-0192
EPA Form 6200-04
Expires: mm-dd-yyyy
INSTRUCTIONS FOR COMPLETING CERCLA 128(a) STATE AND TRIBAL
PROGRAM ACTIVITY LEVELS (PALs) REPORTING FORM
GENERAL INSTRUCTIONS
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 approximately one 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.

Overview:
As specified in your cooperative agreement terms and conditions, all CERCLA 128(a) State and
Tribal cooperative agreement recipients must report to EPA on a regular basis. This OMB and
EPA approved reporting form (OMB No. 2050-0192, EPA Form 6200-04) supplements your
Quarterly or Semiannual Reports with information about specific activities and accomplishments
that EPA deems necessary to adequately monitor and evaluate progress toward goals defined in
the cooperative agreements. Please contact your EPA Regional representative if you have any
questions when completing this form.
Compared to the Quarterly or Semiannual Reports, the PALs Form contains quantitative
information on eight specific measures of recipient performance. Reporting on these specific
activities and accomplishments must be provided in the attached PALs Form rather than in the
Quarterly or Semiannual Reports.

When to Submit:
Cooperative agreement recipients must submit a PALs form annually when the annual funding
submission is due to EPA. Generally, this occurs December 15.
To Whom to Submit:
Cooperative agreement recipients must submit PALs Reporting Forms to their EPA Regional
Representative identified in the terms and conditions or the cooperative agreement. If data is
entered online it will automatically be delivered to the EPA Regional Representative.
How to Submit:
The Assessment, Cleanup, and Redevelopment Exchange System (ACRES) is available online
and is the preferred method for the CERCLA 128(a) State and Tribal cooperative agreement
recipients to enter and submit the PALs Reporting Form. Electronica reporting is optional. The
PALs Reporting Form may also be submitted in hard copy via e-mail to the EPA Regional
Representative.
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OMB No. 2050-0192
EPA Form 6200-04
Expires: mm-dd-yyyy

DETAILED INSTRUCTIONS FOR COMPLETING EACH ITEM ON FORM
PART I – COOPERATIVE AGREEMENT RECIPIENT INFORMATION
1. State or Tribe. Enter the state or tribe that received the CERCLA 128(a) cooperative
agreement.
2. Cooperative Agreement Recipient Name. Enter the cooperative agreement recipient
name. Use the official name provides in the cooperative agreement, unless otherwise
directed by the EPA Regional Representative.
3. Cooperative Agreement Number. Enter the cooperative agreement number. Use the
number as provided in the cooperative agreement.
PART II – PROGRAM ACTIVITY INFORMATION
4. Select one or more of the following environmental programs where CERCLA 128(a)
funds are used to support capacity building (general program support, non-sitespecific work. Indicate, as appropriate, which environmental programs are supported by
CERCLA 128(a) funds. The list of programs are Brownfields, Underground Storage
Tanks/Leaking Underground Storage Tanks, Federal Facilities, Solid Waste, Superfund,
Hazardous Waste Facilities, and/or VCP (Voluntary Cleanup Program, Independent
Cleanup Program, etc.) Other.
5. Number of properties (or sites) enrolled in a response program during the most
recent fiscal year. Enter the number of properties enrolled in the response program.
Note: Please refer to the definition in Part IV for Enrolled and note that it should include
both traditional enrollment programs and programs that track properties under other
oversight activities.
6. Number of properties (or sites) where documentation indicates that cleanup work is
complete AND all required Institutional Controls (ICs) are in place or not required.
Enter the number of properties where documentation demonstrated that all cleanup work
is completed and all required ICs are in place or not required.
7. Total number of acres associated with properties (or sites) identified in question
number 6 above. Enter the total number of acres associated to the properties identified in
question 6.
8. Date of the last update to the Public Record. Enter the date of the last Public Record
for the Response Program.
9. OPTIONAL – Total number of properties where assistance was provided, but the
property was not enrolled in a response program. Enter the total number of properties
where assistance was provided but the property was not enrolled in a response program.
10. Number of audits/inspections/reviews/other conducted to ensure engineering and
institutional controls are still protective. Enter the number of audits, inspections,
reviews, or other conducted to ensure properties with engineering and institutional
controls are still in place and protective of human health and the environment.
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EPA Form 6200-04
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11. Did you develop or revise legislation, regulations, codes, guidance documents or
policies related to establishing or enhancing your Voluntary Cleanup
Program/Response Program during the most recent fiscal year? Enter whether your
program has developed or revised lesistlation, regulations, codes, guidance documents or
policies related to your program in the past year. If yes, please indicate the type and
whether it was new or revised.

PART IV - DEFINITIONS
Properties: As defined in the Brownfields Program’s Property Profile Form (PPF) it is a
“contiguous piece of land under unitary ownership.” A “site” for some programs may include
more than one property. When information is available provide the number of properties for a
site as part your total property count.
Enrolled: Enrolled for the purposes of this program activity level sheet, properties (or site)
activities may include oversight, enforcement, assessment, cleanup, cleanup planning,
implementation of institutional or engineering controls, and monitoring. For some programs
there may be an official entrance procedure (registration and acceptance, i.e. VCPs, Response
Programs) whereas, for other programs it may include properties identified for action(s) by
Response Program officials. Properties where other technical assistance is provided should not
be included, but instead captured under #9.
For example, if 128(a) program funding contributes to several programs under your response
program
(i.e., VCP, Brownfields, and UST/LUST) and these programs oversaw cleanup plans, IC
tracking, etc. for
100 properties (or sites) then this number of 100 would be included in response to #5.
Response Program: Any state or tribal land program benefiting from CERCLA 128(a)
funding may include a response program that focuses on hazardous and/or solid waste
contamination. A response program may include both broader capacity building activities
(e.g., regulation development, database tracking enhancements; or staff training) and sitespecific activities (e.g., brownfield assessment or cleanup, cleanup oversight, or public
participation for cleanup planning).
Required institutional controls (or land use controls): As required by state/tribal/local law,
regulation, or ordinance as necessary to protect the environment and/or public health. In place
institutional controls (as defined in the Brownfield Program’s PPF) generally fall under four
general categories
proprietary controls (e.g., easements, covenants);
governmental controls (e.g., ordinances, zoning, building codes, drilling permit
requirements);
informational devices (e.g., state registries, deed notices,
advisories), and enforcement/permit tools (e.g., order, permits,
consent decrees).
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OMB No. 2050-0192
EPA Form 6200-04
Expires: mm-dd-yyyy
Assistance: Examples of assistance include: working with potential purchasers for properties
not being addressed under the response program; supporting a brownfield grantee to identify
next steps for a particular property where they have a concern for contamination; technical
review of site assessment documents, quality assurance plans, CERCLA 104(k) grantee
applications, etc. This section would not be for those reviews/technical assistance provided to
properties (or sites) listed under #5.

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