http://www.epa.gov/region4/rcra/bflr/documents/tbaapplicationr.doc
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EPA Region 4 - Targeted Brownfield
Assessment
Application Form
Applicant Organization ____________________________________________________
Address_________________________________________________________________
City______________________________ State __________________ Zip___________
Contact person ___________________________________________________________
Phone _________________
Fax _________________ E-mail _____________________
Applicant is: (check one)
local government state/tribal
government
council of government non-profit other_____________________________
Site Name _______________________________________________________________
Site Address _____________________________________________________________
City______________________________ State __________________ Zip __________
Current Site ownership: Name___________________________________________
Address
________________________________________
City
____________________ State
_______ Zip _______
Phone
_______________ E-mail ____________________
Site Zoning ____________________ Total acreage of site (approx)
________________
# Buildings on Site Approx Sq Footage Describe general building conditions
________________________________________________________________________________________________________________________________________________________________________________________________________________________
Is the property owned by the Applicant? ______________________________________
If property is not owned by the applicant, does the applicant
envision difficulty in obtaining legal permission to enter the property to
conduct environmental site assessment activities? YES NO
To the best of your knowledge, briefly describe any
involvement of your state’s environmental agency (e.g., FDEP, SCDHEC, ADEM,
EPA) in enforcement or oversight of assessment/cleanup activities at the candidate
site: ____________________________
________________________________________________________________________________________________________________________________________________
Past Uses of Site (type of manufacturing, industry,
residential, etc) and Approx Dates
________________________________________________________________________________________________________________________________________________________________________________________________________________________
Prior Assessment Activities
None Unknown
Describe prior site assessment activities or attach
“conclusion” section of report(s):
________________________________________________________________________________________________________________________________________________________________________________________________________________________
Site Assessment Needs
Phase I
Phase II Develop cleanup options
and cost estimates
________________________________________________________________________________________________________________________________________________________________________________________________________________________
Anticipated Future Use: Residential Recreational
Commercial/Retail Industrial
Describe applicants proposed vision for reuse: _________________________________
________________________________________________________________________________________________________________________________________________
Describe proposed funding sources for any site
evaluation/cleanup and current or past evidence of developer interest: ______________________________________________
________________________________________________________________________________________________________________________________________________
Briefly describe any public interest and/or community involvement
in site reuse planning: ________________________________________________________________________________________________________________________________________________________________________________________________________________________
Submit completed form to: Bob
Rosen
Targeted
Brownfield Assessment Program
US
Environmental Protection Agency – Region 4
61
Forsyth Street S.W.
Atlanta
GA 30303
Phone: 404-562-8761
Fax: 404-562-8689
Or email to:
rosen.bob@epa.gov
EPA will review the information contained in this
application and may contact you with additional questions and/or to arrange a
site visit.