Address Matching- House Number

Address Matching- Block Face

Address Matching- Street Centerline

Address Matching- Nearest Intersection

Address Matching- Primary Name

Address Matching- Digitized

Address Matching- Other

Census Block- 1990 Centroid

Census- Other

GPS Phase Kinematic Position

GPS (Pseudo Range) Differential

GPS (Pseudo Range) Precise Position

GPS (Pseudo Range) Standard Position (SA Off)

GPS (Pseudo Range) Standard Position (SA On)

Interpolation- Map

Interpolation- Photo

Interpolation- Satellite

Interpolation- Other

Loran C

Public Land Survey Section

Classical Survey

Zip Code- Centroid

Global Positioning Method- Unspecified Parameters

1. Cooperative Agreement Recipient Name (State/Tribe for 

Section 128(a) Cooperative Agreements; requestor/contractor for 

TBAs):

United States

ENVIRONMENTAL PROTECTION AGENCY

Washington, DC 20460

PROPERTY PROFILE FORM—Brownfields

Public reporting burden for this collection of information is estimated to average x.xx hours per response, including the time for reviewing instructions, searching 

data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden 

estimate, or any other aspect of this collection of information, including suggestions for reducing this burden, to the Environmental Protection Agency, Office of 

Environmental Information, Code 2822T, Washington, DC 20460; and to the Paperwork Reduction Project, Office of Management and Budget, Washington, DC 

20503. DO NOT RETURN your form to either of these addresses. Send your completed form to the address provided by the issuing office.

COOPERATIVE AGREEMENT RECIPIENT INFORMATION

2. Cooperative Agreement Number (Contract number for 

TBAs): 

PART I- PROPERTY INFORMATION

3. What type of cooperative agreement funding is being used for this property?

4. For Assessment, Cleanup, and Revolving Loan Fund cooperative agreements, what type of funding is being used at 

this property? 

 Assessment

 Revolving Loan Fund 

 Section 128(a) – State and Tribal Response 

 TBA (EPA Regions Only) Cleanup 

 Hazardous Substance Petroleum Both

Draft For Approval 

OMB Number No. xxx-xxxx 

Expires mm-dd-yyyy

 Area Wide Planning 

 Multi-Purpose Grant

GPS Code (Pesudo Range) Standard-Service Correction

SPOT Satellite

Multi-Spectral Scanner

Thematic Mapper

7b. City: Public Land Survey Eight Section

7c. County: 7d. State: Public Land Survey Sixteenth Section

Public Land Survey Footing

Zip Code Plus 4

Entrance Point of a Facility or Station

Center of a Facility or Station

Point where Substance Enters Facility/Monitoring Site

Facility/Monitoring Site Boundary Point

Point where Substance is Processed, Treated, Settled or Stored

Point where Substance is Released

Point where Substance is Monitored

11f. Horizontal Reference Datum (Choose one): Other Point

11d. Source Map Scale Number (Only if a map/photo 

was used):

11e. Reference Point (e.g., Center of Facility or Station):

7e. ZIP Code: 

11a. Latitude

 (Use 00.000000 decimal 

degree format):

Date of Enrollment: ID Number (if applicable):

11b. Longitude 

 (Use -000.000000 decimal 

degree format):

11c. Horizontal Collection Method:

STATE & TRIBAL BROWNFIELDS/VOLUNTARY RESPONSE PROGRAM INFORMATION

PROPERTY GEOGRAPHIC INFORMATION (EPA Brownfields Program, or its contractors, will 

provide complete latitude/longitude information if cooperative agreement recipients are unable)

10. State & Tribal Program Enrollment (If the property is not enrolled in a state program, check the Property Not Enrolled check box):

7a. Street Address:

PROPERTY BACKGROUND INFORMATION

6. Property Name:

8. Size (in acres): 9. Parcel Number(s):

5a. Indicate if this form is the initial or Updated Form: 5b. If "Updated Form," what's the ACRES Property ID?

 Assessment

 Revolving Loan Fund 

 Section 128(a) – State and Tribal Response 

 TBA (EPA Regions Only) Cleanup 

 Initial Form Updated Form

NAD27-North American Datum of 1927

NAD83-North American Datum of 1983

WGS84-World Geodetic System of 1984

 Hazardous Substance Petroleum Both

This Property Is Not Enrolled 

in a State or Tribal Program

Draft For Approval 

OMB Number No. xxx-xxxx 

Expires mm-dd-yyyy

 Area Wide Planning 

 Multi-Purpose Grant

 Assessment

 Revolving Loan Fund 

 Section 128(a) – State and Tribal Response 

 TBA (EPA Regions Only) Cleanup 

 Initial Form Updated Form

NAD27-North American Datum of 1927

NAD83-North American Datum of 1983

WGS84-World Geodetic System of 1984

 Hazardous Substance Petroleum Both

This Property Is Not Enrolled 

in a State or Tribal Program

Draft For Approval 

OMB Number No. xxx-xxxx 

Expires mm-dd-yyyy

 Area Wide Planning 

 Multi-Purpose Grant

EPA Form # xxxx-xx (x-xxxx) 
If Other

Table B - Contaminants and Media Affected (check all that apply):

Found Cleaned Up Affected Cleaned Up

Petroleum/Petroleum Products

Lead

VOCs

Other Metals

Air

Surface Water

Ground Water

Controlled Substances

CONTAMINANTS & MEDIA AFFECTED INFORMATION (Mandatory for all cooperative agreement types)

Contaminants

Soil

Class of Contaminant REC* Media

12b. If Unknown, Select Reason:

Media

Source of Funding

(enter one source of funding per line; do not 

include funding received prior to the award of this 

EPA CA

Environmental Assessment Detail

Name of Entity

Providing Funds

State/Tribal 

(exclude 

§128(a) 

funds)

This 

US EPA 

CA

Private/

Other

PART II- ENVIRONMENTAL ACTIVITIES

Completion 

Date

ENVIRONMENTAL ASSESSMENT INFORMATION (Mandatory for Assessment Cooperative Agreements, State and Tribal Property-Specific 

Assessments, and TBAs; and, if information is available, for Cleanup and RLF cooperative agreement recipients. CA = Cooperative Agreement)

Local 

Gov't

Amount of Funding 

Expended on this 

Activity 

Other 

Activity Federal

Start 

Date

Table A – Environmental Assessment Activity (If there are multiple assessments, please use a separate line for each assessment)

12a. Indicate Whether Cleanup is Necessary:

Asbestos

Building Materials

No Media Affected

Sediments

Pesticides

SVOCs

Drinking Water

PCBs

Indoor Air

Unknown

Yes No Unknown

Cleanup 

Cooperative 

Agreement

RLF 

Subgrant

Section 128(a) 

RLF State/Tribal Loan

NFA Environmental Professional Certified

EPA Form # XXXX-XX (X-XXXX)

14a. Cleanup Activity Completion Date: 15. Acres Cleaned Up:

14b. Cleanup Completion Documentation

Date:

Type Amount Type Amount

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

State/Tribal 

(exclude §128(a) 

funds)

Local 

Gov't

Date RLF 

Loan 

Signed 

No Contaminants 

17. Number of Cleanup Jobs Leveraged:

*REC = Recognized Environmental Conditions 

18. If EPA Brownfields funding was used, indicate the type and amount (If any non-EPA funding was used, fill out Table C):

16. Date No Further Action/Cleanup Completion Document Issued 

 (If the property was not enrolled in a state or tribal program, leave blank):

Unknown

13. Cleanup Activity Start Date:

ENVIRONMENTAL CLEANUP INFORMATION (Mandatory for Cleanup and RLF Cooperative Agreements and State & Tribal PropertySpecific Cleanups; and, if information is available, for Assessment Cooperative Agreements and TBAs)

Other Contaminants 

PAHs

Unknown

Private/

Other

Cost 

Share

Amount of Funding 

Expended on this Activity 

Name of Entity Providing 

Funds Activity Funded

Cleanup 

Cooperative 

Agreement

RLF 

Subgrant

Section 128(a) 

RLF State/Tribal Loan

NFA Environmental Professional Certified

Yes No Unknown

Cleanup 

Cooperative 

Agreement

RLF 

Subgrant

Section 128(a) 

RLF State/Tribal Loan

NFA Environmental Professional Certified

EPA Form # XXXX-XX (X-XXXX)
Additional Institutional Controls Information:

Address of Data Source (URL if available):

Date:

20b. If Engineering Controls were required, indicate the category (check all that apply):

Additional Engineering Controls Information:

19a. Indicate whether Institutional Controls are required:

19c. Indicate whether Institutional Controls in place:

20a. Indicate whether Engineering Controls are required:

PART II- ENVIRONMENTAL ACTIVITIES (continued)

19b. If Institutional Controls were required, indicate the category (check all that apply):

INSTITUTIONAL & ENGINEERING CONTROLS INFORMATION (Mandatory for all cooperative agreement types)

Yes No

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

Informational Devices (e.g., state registries, 

deed notices)

Governmental Controls (e.g., zoning, building codes)

Enforcement/Permit Tools (e.g., permits, 

consent decrees)

Yes No

Unknown

Yes No Unknown

Greenspace

Residential

Commercial

Industrial

Yes No

Cover Technologies (e.g., Capping) Immobilization Process (e.g., 

Encapsulation, In-Situ Solidification)

Security (e.g., Guard,

Fences) 

Engineered Barriers (e.g., 

Slurry Walls, Sheet)

Other 

Multi-story

EPA Form # XXXX-XX (X-XXXX)

Date: 

Other 

Federal State/Tribal 

Local 

Gov't

Acres Sq. Ft. Sq. Ft.

Actual

Source of Funding 

(Enter one source of funding per line; do not include funding 

received prior to the award of this EPA Cooperative Agreement) 

Acres

24. Future Use, Planned and Actual Acreage (Check all that apply. For properties with multi-story buildings only, please indicate both the entire 

square footage and the square footage for each type of reuse (e.g., a three-story building with first floor commercial and remaining floors residential). 

Name of Entity Providing 

Funds

22. Redevelopment Completion Date:

Address of Data Source (URL if available):

REDEVELOPMENT AND OTHER LEVERAGED ACCOMPLISHMENTS (Mandatory for Assessment, Cleanup and RLF Cooperative 

Agreements; and, if information is available, for State and Tribal Property Specific Activities and TBAs)

Table D- Redevelopment Leveraged Funding Detail

20c. Indicate whether Engineering Controls in place: 

21. Redevelopment Start Date:

23. Number of Redevelopment Jobs Leveraged:

Amount of Funding 

Expended on this 

Activity 

Private/

Other Activity Funded

Planned

Yes No

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

Informational Devices (e.g., state registries, 

deed notices)

Governmental Controls (e.g., zoning, building codes)

Enforcement/Permit Tools (e.g., permits, 

consent decrees)

Yes No

Unknown

Yes No Unknown

Greenspace

Residential

Commercial

Industrial

Yes No

Cover Technologies (e.g., Capping) Immobilization Process (e.g., 

Encapsulation, In-Situ Solidification)

Security (e.g., Guard,

Fences) 

Engineered Barriers (e.g., 

Slurry Walls, Sheet)

Other 

Multi-story

Yes No

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

Informational Devices (e.g., state registries, 

deed notices)

Governmental Controls (e.g., zoning, building codes)

Enforcement/Permit Tools (e.g., permits, 

consent decrees)

Yes No

Unknown

Yes No Unknown

Greenspace

Residential

Commercial

Industrial

Yes No

Cover Technologies (e.g., Capping) Immobilization Process (e.g., 

Encapsulation, In-Situ Solidification)

Security (e.g., Guard,

Fences) 

Engineered Barriers (e.g., 

Slurry Walls, Sheet)

Other 

Multi-story

EPA Form # XXXX-XX (X-XXXX)
Acres

PART II- ENVIRONMENTAL ACTIVITIES (continued)

26. Indicate whether photographs are available:

25. Property Highlights:

ANECDOTAL PROPERTY INFORMATION (If information is available for all cooperative agreement types)

PROPERTY PHOTOGRAPH INFORMATION

29. Predominant Past Use(s) (Check all that apply. For properties with multi-story buildings only, please indicate both entire square footage and the 

square footage for each type of past use (e.g., a three-story building with first floor commercial and remaining floors residential.)

PART III- ADDITIONAL PROPERTY INFORMATION

PROPERTY HISTORY INFORMATION

28. Property Description / History / Past Ownership:

27. Indicate whether video is available:

Square Feet

Actual

Commercial

Industrial

Greenspace

Residential

 Government (Tribal, State, Local) Private

 Yes No

 Yes No Unknown

Yes No Yes No

Multi-story building

EPA Form # XXXX-XX (X-XXXX)

Date:

Date:

OWNERSHIP & SUPERFUND LIABILITY (Mandatory for Cleanup and RLF Cooperative Agreements)

30a. Ownership Entity:

31b. If “yes,” did Superfund federal landowner liability

protections factor into the ownership change?

31a. During the life of the cooperative agreement, did 

ownership change?

30b.Current Owner:

Signature

33. US EPA Regional Representative

Name (please print): Signature

PART IV- APPROVALS

Name (please print):

32. Cooperative Agreement Recipient Project Manager

Commercial

Industrial

Greenspace

Residential

 Government (Tribal, State, Local) Private

 Yes No

 Yes No Unknown

Yes No Yes No

Multi-story building

EPA Form # XXXX-XX (X-XXXX)