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

5a. Indicate if this form is the initial or Updated Form: Global Positioning Method- Unspecified Parameters

3. What 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

ENVIRONMENTAL PROTECTION AGENCY

Washington, DC 20460

PROPERTY PROFILE FORM—Brownfields

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, 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

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

 Assessment

 Revolving Loan Fund 

 Section 128(a) – State and Tribal Response 

Program

 TBA (EPA Regions Only)

 Cleanup 

 Hazardous Substance Petroleum Both

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:

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

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

7a. Street Address:

PROPERTY BACKGROUND INFORMATION

7e. Zip code: 

6. Property Name:

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 Property Not Enrolled check box):

11a. Latitude

 (use 00.000000 decimal 

degree format):

Date of Enrollment: ID Number (if applicable):

11b. Longitude 

 (use -000.000000 decimal 

degree format):

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

was used):

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

11c. Horizontal Collection Method:

STATE & TRIBAL BROWNFIELDS/VOLUNTARY RESPONSE PROGRAM INFORMATION

 Assessment

 Revolving Loan Fund 

 Section 128(a) – State and Tribal Response 

Program

 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

Property Not Enrolled in a 

State or Tribal Program

EPA Form 6200-03 (9-2006)

 Assessment

 Revolving Loan Fund 

 Section 128(a) – State and Tribal Response 

Program

 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

Property Not Enrolled in a 

State or Tribal Program

DRAFT
Found 

Cleaned 

Up Affected

Cleaned 

Up

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

12. Indicate whether cleanup is required:

Asbestos

Other 

Activity Federal

Start 

Date

Lead

Class of Contaminant

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

Petroleum/Petroleum Products

VOCs

PCBs

PART II- ENVIRONMENTAL ACTIVITIES

ENVIRONMENTAL ASSESSMENT INFORMATION (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 Water

Ground Water

Drinking Water

Sediments

No Media Affected

Completion 

Date

Contaminants

Media

Soil

Controlled Substances

State/Tribal 

(exclude 

§128(a) 

funds)

This 

US EPA 

CA

Private/

Other

Amount of 

Funding 

Expended on this 

Activity

Media

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

Environmental Assessment Detail

Unknown

Yes No Unknown

Cleanup Cooperative 

Agreement

RLF Subgrant

Section 128(a) State/Tribal 

Cooperative Agreement RLF Loan

DRAFT

Type Amount Type Amount

*REC = Recognized Environmental Conditions 

Unknown

No Contaminants 

13. Cleanup Activity Start Date:

ENVIRONMENTAL CLEANUP INFORMATION (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 type 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

Amount 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:

Yes No Unknown

Cleanup Cooperative 

Agreement

RLF Subgrant

Section 128(a) State/Tribal 

Cooperative Agreement RLF Loan

Yes No Unknown

Cleanup Cooperative 

Agreement

RLF Subgrant

Section 128(a) State/Tribal 

Cooperative Agreement RLF 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:

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)

19a. Indicate whether Institutional Controls are required:

19c. Indicate whether Institutional Controls in place:

20a. Indicate whether Engineering Controls are required:

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 building

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

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

Name of Entity Providing Funds

Amount of Funding 

Expended on this Activity

22. Redevelopment Completion Date:

Table D- Redevelopment Leveraged Funding Detail

21. Redevelopment 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 Type(s) of Greenspace Created:

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 building

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):

PART III- ADDITIONAL PROPERTY INFORMATION

PROPERTY HISTORY INFORMATION

29. Property Description / History / Past Ownership:

28. Indicate whether video is available:

PART II- ENVIRONMENTAL ACTIVITIES (continued)

27. Indicate whether photographs are available:

26. Property Highlights:

ANECDOTAL PROPERTY INFORMATION (as available for all cooperative agreement types)

PROPERTY PHOTOGRAPH INFORMATION

Commercial

Industrial

Greenspace

Residential

 Government (Tribal, State, Local) Private

 Yes No Yes No Unknown

Yes No Yes No

Multi-story building

DRAFT

acres sq. ft. acres sq. ft.

Date:

Date:

PART IV- APPROVALS

Name (please print):

33. Cooperative Agreement 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 LIABILITY (Mandatory for Cleanup and RLF Cooperative Agreements)

Commercial

Industrial

Greenspace

Residential

 Government (Tribal, State, Local) Private

 Yes No Yes No Unknown

Yes No Yes No

Multi-story building

DRAFT