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 **5a.** Indicate if this form is the initial or Updated Form: **3.** W hat type of cooperative agreement funding is being used for this property? **5b.** If "Updated Form," what's the ACRES Property ID? **4** . For Assessment, Cleanup, and Revolving Loan Fund cooperative agreements, what type of funding is being used at this property? 

## United States

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

**Washington, DC 20460 PROPERTY PROFILE FORM—Brow**  **nfields** Public reporting burden for this collection of information is estimated to average 1.50 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. **COOPERATIVE AGREEMENT RECIPIENT INFORMA TION**  **2** . Cooperative Agreement Number (contract number for TBAs) : 

## PA **RT I- PROPERTY INFORMA TION**  **1.** Cooperative Agreement Recipient Name (State/Tribe for Section 128(a) Cooperative Agreements; requestor/contractor for TBAs) : Form Approved OMB No. 2050 - 0192 Expires 07 - 31 - 2009 

### A ssessm ent Revolving Loan Fund 

### S ection 128(a) – Sta te and T ribal Response Pr ogram TBA (EPA R egions On ly

) Cleanup 

### Haz ardous S ubstance Petroleum 

### B oth

GPS Code (Pesudo Range) Standard-Service Correction

Interpolation- Digital Map Source (TIGER)

SPOT Satellite

Multi-Spectral Scanner **7b** . City:
Thematic Mapper **7c** . County: **7d.** State:

Public Land Survey Eight Section

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 **11f.** Horizontal Reference Datum (Choose one) :

Point where Substance is Monitored

Other Point EPA Form 6200-03 (9-2006) **5a.** Indicate if this form is the initial or Updated Form: **9.** Parcel Number(s): **8.** Size (in acres): **5b.** If "Updated Form," what's the ACRES Property ID? **7a.** Street Address: **PROPERTY BA CKGROUND INFORMA**  **TION 7e.**  Zip code: **6.** Property Name:

**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 Property Not Enrolled check box) : **11a.** Latitude (use 00.000000 decimal degree format) : ID Number (if applicable): Date of Enrollment: **11b** . Longitude (use -000.000000 decimal degree format): **11d.** Source Map Scale Number (Only if a map/photo wa s used): **11e.** Reference Point (e.g., Center of Facility or Station) : **11c.** Horizontal Collection Method: **STA TE & TRIBA**  **L BROWNFIELDS/VOLUNTA RY RESPONSE PROGRA**  **M INFORMA TION**  

### A ssessm ent Revolving Loan Fund 

### S ection 128(a) – Sta te and T ribal Response Pr ogram TBA (EPA R egions On ly

) Cleanup 

### I nitial F orm U pdated Form



### NA D2 7-N orth Ame ri can Datumof 1927 

### NA D83-N orth A me ri ca n Datumof 1983 WGS84 -World Geodetic S ystemof 1984 Haz ardous S ubstance Petroleum 

### B oth Pr opert y N ot En rol led in a Stateo r Tribal Pr

ogram EPA Form 6200-03 (9-2006) 

### A ssessm ent Revolving Loan Fund 

### S ection 128(a) – Sta te and T ribal Response Pr ogram TBA (EPA R egions On ly

) Cleanup 

### I nitial F orm U pdated Form



### NA D2 7-N orth Ame ri can Datumof 1927 

### NA D83-N orth A me ri ca n Datumof 1983 WGS84 -World Geodetic S ystemof 1984 Haz ardous S ubstance Petroleum 

### B oth Pr opert y N ot En rol led in a Stateo r Tribal Pr

ogram
DRAFTFound Cleaned Up Affected Cleaned Up 

### Table A **– Environmental A**

**ssessment A ctivity**  (If there are multiple assessments, please use a separate line for each assessment) 

### 12. Indicate whether cleanup is required: Asbestos Other Federal Activity Start

Date 

### Lead Class of Contaminant **Table B - Contaminants and Media A ffected**  (check all that apply ): 

### Petroleum/Petroleum Products VOCs PCBs 

## PA **RT II- ENVIRONMENTA L A** **CTIVITIES ENVIRONMENTA**  **L A SSESSM**  **ENT INFORMA TION**  (mandatory for Assessment Cooperative Agreements, State & Tribal Property-Specific Assessments, and TBAs; as available for Cleanup and RLF cooperative agreement recipients; CA = Cooperative Agreement)

**Source of Funding** (enter one source of funding per line; do not include funding received prior to the award of this Local Gov't REC* 

### Name of Entity Providing Funds Other Metals Air Surface W ater Ground W ater Drinking W ater Sedim ents No Media Affected Completion Date 

### Contaminants Media Soil Controlled Substances State/Tribal (exclude §128(a) funds) This US EPA CA Private/ Other 

### Am ount of Funding Expended on this Activity **Me dia**  **CONTA MINA**  **NTS & MEDIA A**  **FFECTED INFORMA TION**  (mandatory for all cooperative agreement types) **Environmental A**

**ssessment Detail**
Unknown Unk nown Ye s No

Cl eanup Cooperat iv

e Ag reement RLF Su bgrant Se cti on 128(a) Sta te/Tri bal Cooperat iv

e Ag reem ent RL F Loan 

### DRAFT Ty pe Am ount Ty pe Am ount *REC = Recognized Environm ental Conditions Unknown No Contaminants **13.** Cleanup Activity

Start Date: **ENVIRONMENTA L CLEA**  **NUP INFORMA TION**  (mandatory for Cleanup and RLF Cooperative Agreements and State & Tribal Property-Specific Cleanups; as available for Assessment Cooperative Agreements and TBAs) 

### 14. Cleanup Activity

Completion Date: **15.** Acres Cleaned Up: Date RLF Loan Signed 

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

### Other Contaminants

PAHs **17.** Number of Cleanup Jobs Leveraged: Other Federal State/Tribal (exclude §128(a) funds) Local

Gov't 

### Am ount of Funding Expended on this Activity Private/ Other **Source of Funding** (enter one source of funding per line; do not include funding received prior to the award of this EPA Cooperative Agreement) 

### Table C - Environmental Cleanup Leveraged Funding Detail Name of Entity

Providing Funds **16.** Date No Further Action/Cleanup Completion Document Issued (If the property

was not enrolled in a state or tribal program, leave blank) 

### : Date: Unk nown Ye s No

Cl eanup Cooperat iv

e Ag reement RLF Su bgrant Se cti on 128(a) Sta te/Tri bal Cooperat iv

e Ag reem ent RL F Loan Unk nown Ye s No

Cl eanup Cooperat iv

e Ag reement RLF Su bgrant Se cti on 128(a) Sta te/Tri bal Cooperat iv

e Ag reem ent RL F Loan 

### DRAFT

### 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:



## 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) **19a.** Indicate whether Institutional Controls are required: **19c.** Indicate whether Institutional Controls in place: **20a.** Indicate whether Engineering Controls are required: 

### Ye s No Pr opri et ary C ont rols ( e. g. , e as ement s, co ve nant s) In fo rm at io nal D ev

ice s ( e. g. , stater

egi strie s, deed not ic es ) Go ve rn me ntal Cont ro ls (e .g ., z oning, b uilding codes ) 

### En fo rc em ent/Pe rm itT

ool s ( e. g. , p erm its, co ns entd ec rees ) 

### Ye s 

### No 

### Un kn ow n Ye s No Un kn ow n

Greens pac e Res ident ial Com me rc ia l 

### In dus trial 

### Ye s No Cov er Te ch nol ogi es ( e. g. , C appi ng) Im mo biliz at io n Proc es s ( e. g. , En ca ps ulat ion, I n-S itu So lidif ic at io n) Se cu ri ty ( e. g. , G uard, Fe nc es ) En gi neered Ba rriers ( e. g. , Sl urry Wa lls , Sh eet ) Ot her

Mu lt i- sto ry b uilding 

### DRAFT Date: Other Federal State/Tribal Local Gov't 

### acres sq. ft. acres sq. ft. acres sq. ft. acres sq. ft. **24.** Future Use and Estimated Acreage ( check all that apply; For properties with multi-story buildings only, please indicate also the square footage for each type of reuse (e.g. a three story building with first floor commercial and remaining floors residential). 

### 20c. Indicate whether Engineering Controls in place: Address of Data Source (URL if available) 

### : **REDEVELOPMENT A ND OTHER LEVERA** **GED A CCOMPLISHMENTS**  (Mandatory for Assessment, Cleanup and RLF

Cooperative Agreements; as available for State and Tribal Property Specific Activities and TBAs) Name of Entity

Providing Funds Am ount of Funding Expended on this Activity **22.** Redevelopm ent Completion Date: **Table D- Redevelopment Leveraged Funding Detail 21.**  Redevelopm ent Start Date: **23.** Number of Redevelopment Jobs Leveraged: Private/ Other **Source of Funding** (enter one source of funding per line; do not include funding received prior to the award of this EPA Cooperative Agreement) 

### 25. Actual Acreage(s) and Ty pe(s) of Greenspace Created: 

### Ye s No Pr opri et ary C ont rols ( e. g. , e as ement s, co ve nant s) In fo rm at io nal D ev

ice s ( e. g. , stater

egi strie s, deed not ic es ) Go ve rn me ntal Cont ro ls (e .g ., z oning, b uilding codes ) 

### En fo rc em ent/Pe rm itT

ool s ( e. g. , p erm its, co ns entd ec rees ) 

### Ye s 

### No 

### Un kn ow n Ye s No Un kn ow n

Greens pac e Res ident ial Com me rc ia l 

### In dus trial 

### Ye s No Cov er Te ch nol ogi es ( e. g. , C appi ng) Im mo biliz at io n Proc es s ( e. g. , En ca ps ulat ion, I n-S itu So lidif ic at io n) Se cu ri ty ( e. g. , G uard, Fe nc es ) En gi neered Ba rriers ( e. g. , Sl urry Wa lls , Sh eet ) Ot her

Mu lt i- sto ry b uilding 

### DRAFT

### acres sq. ft. acres sq. ft. acres sq. ft. acres sq. ft. **30.** Predominant Past Use(s) (check all that apply; For properties with multi-story buildings only, please indicate also the square footage for each type of reuse (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**  **29.** Property

Description / History

/ Past Ownership: **28.** Indicate whether video is available: 

## PA **RT II- ENVIRONMENTA L A** **CTIVITIES (continued) 27.**  Indicate whether photographs are available: 

### 26. Property

Highlights: **AN ECDOTA**  **L PROPERTY INFORMA TION**  (as available for all cooperative agreement types) **PROPERTY PHOTOGRA PH INFORMA**  **TION** Com me rc ia l Indus tria l Gr eens pac e Res id ent ia l 

### Governm ent (Tri bal, S tate, Local) P ri va te Yes No 

### Yes 

### N o U nk now n 

### No Ye s 

### No Ye s Mu lti- sto ry b uilding



### DRAFT acres sq. ft. acres sq. ft. Date: Date: 

## PA **RT IV- A PPROVA**  **LS** Name (please print): **33. Cooperative A greement Recipient Project Manager**  Signature **34. US EPA**

**Regional Representative** Name (please print): Signature **31a.** Ownership Entity : **32b.** If “yes,” did Superfund federal landowner liability protections factor into the ownership change? **32a.** During the life of the cooperative agreement, did ownership change? **31b** .Current Owner:

**OWNERSHIP & SUPERFUND LIA BILITY**  (Mandatory for Cleanup and RLF Cooperative Agreements) Com me rc ia l Indus tria l Gr eens pac e Res id ent ia l 

### Governm ent (Tri bal, S tate, Local) P ri va te Yes No 

### Yes 

### N o U nk now n 

### No Ye s 

### No Ye s Mu lti- sto ry b uilding



### DRAFT