6200-03 Property Profile Form 6200-03

United States
ENVIRONMENTAL PROTECTION AGENCY
Washington, DC 20460

OMB Number No. 2050-0192
Expires mm-dd-yyyy

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 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

PART I- PROPERTY INFORMATION
COOPERATIVE AGREEMENT RECIPIENT INFORMATION (Mandatory for All Cooperative Agreements)
1. Cooperative Agreement Recipient Name

2. Cooperative Agreement Number

(State/Tribe for

Section 128(a) Cooperative Agreements; Requestor for TBAs):

3. What type of cooperative agreement funding is being used for this property?
Assessment
Section 128(a) – State and Tribal Response
Program
Multipurpose Grant
Revolving Loan Fund
TBA (EPA Regions Only)
Cleanup
4. For Assessment, Cleanup, Multipurpose and Revolving Loan Fund cooperative agreements, what type of funding is being
used at this property?
Petroleum

Hazardous Substance

5a. Indicate if this form is the initial or Updated Form:
Initial Form

Both

5b. If "Updated Form," what's the ACRES Property ID?

Updated Form

PROPERTY BACKGROUND INFORMATION (Mandatory for All Cooperative Agreements)
6a. Property Name:
6b. Property Alias:
7. Property Owner:
Private

Government (Tribal, State, Local)

8b. City:

8a. Street Address:
8c. County:

8d. State:

9. Size (in acres):

8e. ZIP Code:
10. Parcel Number(s):

STATE & TRIBAL BROWNFIELDS/VOLUNTARY RESPONSE PROGRAM INFORMATION
11a. Is this property enrolled in a State or Tribal Voluntary Response Program?
Yes
No
11b. If yes, enter the enrollment date and ID number:
Date of Enrollment:

ID Number (if applicable):
PROPERTY GEOGRAPHIC INFORMATION (EPA Brownfields Program, or its contractors, will
provide complete latitude/longitude information if cooperative agreement recipients are unable)

12a. Latitude

12b. Longitude

(Use 00.000000 decimal degree format):

(Use -000.000000 decimal degree format):

EPA Form # 6200-03

(Not applicable for TBAs):

PART II- ENVIRONMENTAL ACTIVITIES
ENVIRONMENTAL ASSESSMENT INFORMATION (Mandatory for Assessment Cooperative Agreements, Multipurpose Cooperative Agreements with assessments, State and Tribal PropertySpecific Assessments, and TBAs; and, if information is available, for Cleanup and RLF Cooperative Agreements)

Table A – Environmental Assessment Activity (If there are multiple assessments, please use a separate line for each assessment)
This collection of information is approved by
Source of Funding
(enter one source of funding per line; do not include funding received prior to the
OMB under the Paperwork Reduction Act, 44
award
of this EPA CA
U.S.C. 3501 et seq. (OMB Control No. 2050-0192).
Start
Date

Activity Funded

This
US EPA
CA

Completion
Date

13a. Indicate Whether Cleanup is Necessary:

State/Tribal
(exclude
§128(a) funds)

Other Federal

Local
Gov't

Private/
Other

Program
Income

Name of Entity Providing
Funds

Amount of Funding Expended on this Activity

No Unknown

Yes

(If unknown is selected, update whether cleanup is necessary when a final determination is made)
13b. If Unknown, Select Reason:

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

Found

REC*

Media

Media

Cleaned Up

Affected

Cleaned Up

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

PAHs
Other Contaminants
No RECs
No Contaminants
Insufficient Information
*REC = Recognized Environmental Conditions. RECs are most commonly identified during a Phase I Assessment as areas of potential concern. For Controlled Recognized Environmental Conditions, do NOT enter corresponding
information for pre-existing Engineering & Institutional Controls.

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:

Yes

15a. Indicate whether Cleanup/Treatment Technology(ies) were implemented:

No

Unknown

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

Removal of materials (tanks and
piping, etc.)

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

Reduction of contaminants through
Bioremediation/Phytoremediation

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

Additional Cleanup/Treatment Technology(ies) Information:

Address of Data Source (URL if available):
16a. Indicate whether Engineering Controls are required (Do not enter
engineering controls that are managing Controlled Recognized
Environmental Conditions):

Yes

No

Unknown

16b. If Engineering Controls were required, indicate the category (check all that apply):
Cover Technologies (e.g., Capping)

Security (e.g., Guard,
Fences)

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

Engineered Barriers (e.g., Slurry
Walls, Sheet)

Other

Additional Engineering Controls Information:

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

EPA Form # 6200-03

Yes

No

18. Number of Cleanup Jobs Leveraged:

Date:

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
Type
recordkeeping burden for this collection of information is estimated to be one hour per response. Send comments on the Agency’s need for this information, the accuracy of the provided burden estimates and any suggested method
Section 128(a)
State/Tribal
Multipurpose

Cost
Share

Cleanup

Cost
Share

RLF Loan

Cost
Share

Program
Income

Interest Rate

Repayment Period

Date RLF loan Signed

Cost
Share

RLF
RLF
Subgrant
Subgrant

Program
Income

Date RLF Subgrant
Signed

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
State/Tribal
EPA sources that are NOT (exclude §128(a)
Brownfields funding)
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)
Yes

20a. Indicate whether Institutional Controls are required:

No

Unknown

20b. If Institutional Controls were required, indicate the category (check all that apply):
Governmental Controls (e.g., zoning, building codes,
land use restriction )

Proprietary Controls (e.g., easements, covenants)

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

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

Additional Institutional Controls Information:

Address of Data Source (URL if available):
Yes

20c. Indicate whether Institutional Controls in place:

No

Date:

21. 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 an Qualified Professional

Date Received:

Other forms of documentation (subject to Project Officers approval). Please Describe:

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)

22a. Redevelopment Start Date:

22b. 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 Government

Private/Other

Name of Entity Providing Funds

Activity Funded

Amount of Funding Expended on this
Activity

23. Number of Redevelopment Jobs Leveraged:
24. Redevelopment Land Use (Check all that apply). Indicate the acreage or square footage for each type of redevelopment on the property.
Acres
Residential
Greenspace

EPA Form # 6200-03

or

Square Feet

Residential
Greenspace

Industrial
Commercial

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

26. 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