Eligibility determination for

Targeted Brownfield Assessments with U.S. EPA-lead --

documentation to be completed by EPA

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Section 1 - Property description

1.	Provide the property name, aliases or historic names:

2. Provide the street address of the property:

3. Provide the property latitude and longitude (Degrees/Minutes/Seconds) if known:

4. Define the size of the property to be assessed in acres:

5. A plat map (or an aerial photograph) clearly delineating the property or portion of the property to be assessed would be helpful.

6. Describe any potential pollutants, contaminants or hazardous substances at the property, including petroleum, asbestos, mine wastes and/or meth lab residuals (identify source of information), whether in the air, land, surface water or groundwater. Include information about the source or potential source of such potential pollutants, contaminants or hazardous substances.

7. Describe any potential pollutants, contaminants or hazardous substance adjacent to or otherwise in close proximity to the property, including petroleum, asbestos, mine wastes and/or meth lab residuals (identify source of information), whether in the air, land, surface water or groundwater. Include information about the source or potential source of such potential pollutants, contaminants or hazardous substances.

Section 2 - Applicant Eligibility

8. Did the applicant take title to the property before Jan 11, 2002.

Date of Purchase ______________________________.

9.	At the time the applicant acquired title to the property, did the applicant conduct any investigation into the potential presence of pollutants, contaminants or hazardous substances at or near the property? If so, identify what investigations were conducted and the dates such investigations were made.

10.	Since acquiring title to the property, has the applicant taken measures to ensure that potential pollutants, contaminants and hazardous substances are not released from the property or present a threat to human health or the environment? Explain:

11.	Is the applicant affiliated or related in any way (e.g. family, contract, corporate or financial arrangement, etc.) with any former owner or operator of the property, or with any person who may have generated hazardous substances located at or near the property, or with any person who may have transported or arranged for the transportation of hazardous substances located at or near the property?

_____ No

_____ Yes. Explain the affiliation or relationship:

12.	Does the property meet the definition of "Brownfields" as contained in federal Small Business Liability Relief and Brownfields Revitalization Act (Section 211(a)(39) of the Public Law 107-118 (H.R. 2869))?

____Yes	Real property whose reuse has been complicated by real or perceived contamination.

____Yes	The property is an active, but underutilized industrial/commercial property. Estimate the percentage of the property currently utilized:

____No	This Site is not eligible

13. Does the applicant have or can it obtain access to 100% of the property to be assessed?

____Yes	Applicant owns or controls property.

____Yes	Property is an orphan property.

____Yes	Access agreement is in place with current owner(s).

____No	Working on access agreement with current owner(s) and agreement will be signed ________________________.

____No	Project is ineligible if access to site cannot be obtained.

14.	Has the applicant received in the past, or is it currently receiving, federal brownfields assessment resources for this property?

Explain why TBA is being requested rather than pursuing funding through the Small Business Liability Relief and Brownfields Revitalization Act. Title II, Subtitle A.

____Applied	Already applied for but not currently receiving funding. Work cannot begin until the funding application has been denied or withdrawn. If funding is received, the project may not be eligible for Targeted Brownfields Assessment funds.

____Receiving	If applicant is currently using federal funds for this site, work may not be eligible if it exceeds the 200K cap.

____Past Funding	If yes, list the amount and activities for which the funds were used:___________________________________________.

____No

Section 3 - Project details

15.	Does this site have an end use?

____Yes	Explain:

____Yes	A developer is interested, but no final end users confirmed.

____Yes	Is the end user or developer contributing to the cost of assessment and/or remediation?	Explain:

____No	Project is included in community's master land use plan.

____No	Site specific plan is in place or being evaluated.

16.	Specify the proposed future use of the property (Check all that apply):

____Recreational/Residential (includes greenspace).

____Commercial.

____Industrial.

Explain (include estimate of remediation/redevelopment cost if available):

17.	Work requested includes:

____Initial field screening to assess redevelopment options.

Explain:

____Extensive assessment work.

Explain:

19.	Have resources been expended on assessment at this property, including federal/state/state funds including grants and loans?

____Yes	provide the name(s) and amount of the funds used :

____No	Explain (if needed):

20.	Is there a specified timeline in which site assessment activities need to be performed?

____No

____Yes	If yes, define timeline/deadlines for the project (if applicable, please include grant application deadlines, timelines for redevelopment, etc.) below:

*****	*****	*****	*****	*****

Site is eligible ______Yes	______No

Date of U.S. EPA concurrence _________________

TBA Request Form/Mar2004