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 **ENVIRONMENTA L PROTECTION A** **GENCY**

**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, W ashington, 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. 

### COOPERA

**TIVE A GREEMENT RECIPIENT INFORMA**  **TION 2**  . Cooperative Agreement Number (Contract number for TBAs) 

### : 

## PA **RT I- PROPERTY INFORMA TION**  **3.** W hat ty pe of cooperative agreement funding is being used for this property ? **4** . For Assessment, Cleanup, and Revolving Loan Fund cooperative agreements, w hat ty pe of funding is being used at this property? 

### Assessm ent Revolving Loan Fund 

### S ecti on 128(a) – St ate and Tri bal Response TB A (EPA

R egions On ly

) 

### Cleanup H az ardousS ubstance P etrol eum 

### B oth Draft For Approval OMB Number No. xxx-xxxx Expires mm-dd-yyyy


### A rea W ide P la nning M ul ti-P urpose 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) 

### : ID Number (if applicable): 

### Date of Enrollment: **11b** . Longitude (Use -000.000000 decimal degree format): 

### 11c. Horizontal Collection Method: **STATE & TRIBAL BROWNFIELDS/VOLUNTARY RESPONSE PROGRA M INFORMA**  **TION PROPERTY GEOGRA**  **PHIC INFORMA TION**  (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 BA CKGROUND INFORMA**  **TION 6.**  Property

Name: **9.** Parcel Number(s): **8.** Size (in acres): **5b.** If "Updated Form," w hat's the ACRES Property ID? **5a.** Indicate if this form is the initial or Updated Form: 

### Assessm ent Revolving Loan Fund 

### S ecti on 128(a) – St ate and Tri bal Response TB A (EPA

R egions On ly

) 

### Cleanup I nitial F orm U pdated Form



### NA D2 7-North A me ri can Datumof 1927 NA D8 3-N orth A me rican Datumof 1983 WGS8 4-Worl d Geodeti c S ystemof 1984 

### H az ardousS ubstance P etrol eum 

### B oth
Th is Pr opert y I s N ot En rolled in aSta teo r Trib al Program Draft For Approval OMB Number No. xxx-xxxx Expires mm-dd-yyyy


### A rea W ide P la nning M ul ti-P urpose Grant 

### Assessm ent Revolving Loan Fund 

### S ecti on 128(a) – St ate and Tri bal Response TB A (EPA

R egions On ly

) 

### Cleanup I nitial F orm U pdated Form



### NA D2 7-North A me ri can Datumof 1927 NA D8 3-N orth A me rican Datumof 1983 WGS8 4-Worl d Geodeti c S ystemof 1984 

### H az ardousS ubstance P etrol eum 

### B oth
Th is Pr opert y I s N ot En rolled in aSta teo r Trib al Program Draft For Approval OMB Number No. xxx-xxxx Expires mm-dd-yyyy


### A rea W ide P la nning M ul ti-P urpose Grant

EPA Form # xxxx-xx (x-xxxx)If Other **Table B - Contaminants and Media A ffected**  (check all that apply):

Found Cleaned Up Affected Cleaned Up Petroleum/Petroleum Products Lead VOCs Other Metals Air Surface W ater Ground W ater Controlled Substances **CONTA MINA**  **NTS & MEDIA A**  **FFECTED INFORMA TION**  (Mandatory for all cooperative agreement types) **Contaminants** Soil REC* Class of Contaminant 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 A**

**ssessment Detail** Name of Entity Providing Funds State/Tribal (exclude §128(a) funds) This US EPA CA Private/ Other 

### PA **RT II- ENVIRONMENTA L A** **CTIVITIES** Completion Date **ENVIRONMENTA L A** **SSESSMENT INFORMA TION**  (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 Federal Activity Start Date **Table A – Env**  **ironmental A**

**ssessment A ctiv**  **ity** (If there are multiple assessments, please use a separate line for each assessment) **12a.** Indicate W hether Cleanup is Necessary: Asbestos Building Materials No Media Affected Sediments Pesticides SVOCs Drinking W ater PCBs Indoor Air Unknown Unk nown Yes No

Cl eanup Cooperat iv

e Ag reem ent RLF Su bgrant Se cti on 128(a) Sta te/Tri bal RLF L oan NF A En vi ronm ent al Pr ofes si onal C ert if

ie d
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 - Env ironmental Cleanup Lev** **eraged 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: **ENVIRONMENTA L CLEA**  **NUP INFORMA TION**  (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 Cl eanup Cooperat iv

e Ag reem ent RLF Su bgrant Se cti on 128(a) Sta te/Tri bal RLF L oan NF A En vi ronm ent al Pr ofes si onal C ert if

ie d Unk nown Yes No

Cl eanup Cooperat iv

e Ag reem ent RLF Su bgrant Se cti on 128(a) Sta te/Tri bal RLF L oan NF A En vi ronm ent al Pr ofes si onal C ert if

ie d
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:



## PA **RT II- ENVIRONMENTA L A** **CTIVITIES (continued) 19b.**  If Institutional Controls were required, indicate the category (check all that apply): 

### INSTITUTIONA **L & ENGINEERING CONTROLS INFORMA TION**  (Mandatory for all cooperative agreement types) 

### Ye s No Pr opriet ary C ont rol s ( e. g. , e as ement s, cove nant s) Inform at io nal Dev

ic es ( e. g. , sta ter

egis trie s, deed not ice s) Go ve rnm ental Cont rols (e .g ., z oning, b uilding codes ) En forc ement /Pe rm it T ool s ( e. g. , p erm it s, co ns ent d ec rees ) 

### Ye s 

### No Un know n 

### Ye s No Un know n

Gr eens pac e 

### Res ident ia l 

### Com me rc ial 

### In dus tria l 

### Ye s No Cov er Te ch nol ogi es ( e. g. , C apping) Im mobiliz at ion Pr oc es s ( e. g. , En ca ps ulat ion, I n-S itu So lid if icatio n) Se cu rit y ( e. g. , G uard, Fenc es ) En gi neered Ba rri ers ( e. g. , Slu rry Wa lls , Sh eet ) Ot her



### Mu lti-sto ry 

### EPA Form # XXXX-XX (X-XXXX) Date: Other Federal State/Tribal Local Gov't 

### Ac **res Sq. Ft.**  **Sq. Ft. Ac**  **tual Source of Funding**  (Enter one source of funding per line; do not include funding received prior to the award of this EPA Cooperative Agreement) 

### Ac **res 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 A ND OTHER LEVERA** **GED A CCOMPLISHMENTS**  (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** 

### Ye s No Pr opriet ary C ont rol s ( e. g. , e as ement s, cove nant s) Inform at io nal Dev

ic es ( e. g. , sta ter

egis trie s, deed not ice s) Go ve rnm ental Cont rols (e .g ., z oning, b uilding codes ) En forc ement /Pe rm it T ool s ( e. g. , p erm it s, co ns ent d ec rees ) 

### Ye s 

### No Un know n 

### Ye s No Un know n

Gr eens pac e 

### Res ident ia l 

### Com me rc ial 

### In dus tria l 

### Ye s No Cov er Te ch nol ogi es ( e. g. , C apping) Im mobiliz at ion Pr oc es s ( e. g. , En ca ps ulat ion, I n-S itu So lid if icatio n) Se cu rit y ( e. g. , G uard, Fenc es ) En gi neered Ba rri ers ( e. g. , Slu rry Wa lls , Sh eet ) Ot her



### Mu lti-sto ry 

### Ye s No Pr opriet ary C ont rol s ( e. g. , e as ement s, cove nant s) Inform at io nal Dev

ic es ( e. g. , sta ter

egis trie s, deed not ice s) Go ve rnm ental Cont rols (e .g ., z oning, b uilding codes ) En forc ement /Pe rm it T ool s ( e. g. , p erm it s, co ns ent d ec rees ) 

### Ye s 

### No Un know n 

### Ye s No Un know n

Gr eens pac e 

### Res ident ia l 

### Com me rc ial 

### In dus tria l 

### Ye s No Cov er Te ch nol ogi es ( e. g. , C apping) Im mobiliz at ion Pr oc es s ( e. g. , En ca ps ulat ion, I n-S itu So lid if icatio n) Se cu rit y ( e. g. , G uard, Fenc es ) En gi neered Ba rri ers ( e. g. , Slu rry Wa lls , Sh eet ) Ot her



### Mu lti-sto ry 

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

### Ac **res** 

## PA **RT II- ENVIRONMENTA L A** **CTIVITIES (continued) 26.**  Indicate whether photographs are available: 

### 25. Property

Highlights: **AN ECDOTA**  **L PROPERTY INFORMA TION**  (If information is available for all cooperative agreem ent types) 

### PROPERTY PHOTOGRA **PH INFORMA TION**  **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.)



## PA **RT III- A DDITIONA**  **L PROPERTY INFORMA TION**  **PROPERTY HISTORY INFORMA TION**  **28.** Property

Description / History

/ Past Ownership: **27.** Indicate whether video is available:

**Square Feet Ac**  **tual** Com me rc ia l In dus tria l Greens pac e Res id ent ial 

### Governm ent (Tribal, S tate, Local ) P ri vate 

### Yes N o 

### Yes N o U nk now n 

### No Ye s No 

### Ye s

Mu lti-sto ry b ui ld ing



### EPA Form # XXXX-XX (X-XXXX) Date: Date: **OWNERSHIP & SUPERFUND LIA BILITY**  (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 

## PA **RT IV- A PPROVA**  **LS** Name (please print): **32. Cooperative A greement Recipient Project Manager**  Com me rc ia l In dus tria l Greens pac e Res id ent ial 

### Governm ent (Tribal, S tate, Local ) P ri vate 

### Yes N o 

### Yes N o U nk now n 

### No Ye s No 

### Ye s

Mu lti-sto ry b ui ld ing



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