6200-04 Program Activity Level (PAL) Reporting Form 6200-04

United States
ENVIRONMENTAL PROTECTION AGENCY
Washington, DC 20460

Draft For Approval
OMB Control Number:
2050-0192
Expires: mm-dd-yyyy

BROWNFIELDS PROGRAM ACTIVITY LEVEL (PAL) REPORTING 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 approximately 1
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.

The Office of Brownfields and Land Revitalization is requesting the information below to capture impacts from the funding received under the 128(a)
State and Tribal Response Program. Responses should include properties (or sites) that are supported under any hazardous and solid waste
programs. Consider programs impacted by either broader capacity building activities (regulation development, database tracking enhancements, or
staff training) and/or site-specific activities (brownfields assessment, cleanup oversight, or public participation).
Submit completed forms to your project officers and regional response program coordinators on or before the due date of MM-DD_YYYY. Responses
to the questions below should reflect activities for the period covering the last federal fiscal year.

PART I - COOPERATIVE AGREEMENT RECIPIENT INFORMATION
A. State or Tribe

B. Cooperative Agreement Recipient Name

C. Cooperative Agreement Number

PART II - PROGRAM ACTIVITY INFORMATION
1. Select one or more of the following environmental programs where CERCLA 128(a) funds are used to
support capacity building (general program support, non-site-specific work):

Brownfields
Underground Storage Tanks/Leaking Underground Storage Tanks
Federal Facilities
Solid Waste

Superfund

Hazardous Waste Facilities
VCP (Volunteer Cleanup Program, Independent Cleanup Program, etc)
Other
2. Number of properties (or sites) enrolled in a response
program during the most recent fiscal year:
EPA Form #: 6200-04

3. 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:

4. Total number of acres associated with properties (or sites)
identified in question number 6 above:
5. Date of the last update to the Public Record:
6. OPTIONAL – Total number of properties where assistance was
provided, but the property was not enrolled in a response
program:

7. Number of audits/inspections/reviews/other conducted to
ensure engineering and institutional controls are still protective:
Number of Audits
Number of Inspections
Number of Reviews
Other
If Other, please explain:
8. 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?
If yes, please indicate the type and whether it was new or revised?

EPA Form #: 6200-04

Yes

No