ࡱ> '` bjbjLULU .?.?'.TTT ^ $ ,,,Pf,l-d.iB.@4444-6=:D<$xhzhzhzhzhzhzh$jhImh@ 6"-6@@h44siFFF@ 44xhF@xhFF6pbd46. p%,APcxhi0ilc`nBn8ddXn$eT=v>TFo>D>===hh~Fp===i@@@@...+...+Tp6jT6 MICHIGAN DEPARTMENT OF ENVIRONMENTAL QUALITY REMEDIATION DIVISION Application Form for a Site Specific Brownfield Assessment from the Michigan Department of Environmental Quality The Michigan Department of Environmental Quality (MDEQ) conducts Site Specific Assessments (SSAs) at brownfield properties at no cost to communities through a 128(a) grant from the United States Environmental Protection Agency (U.S. EPA). For consideration in the program, this form must be completed by the requestor, to the best of their knowledge, and sent to the MDEQ Brownfield Assessment Program Manager along with a letter requesting the assessment. The request letter should include pertinent information as to why the request is being made for the property and the potential public benefit that will result from redevelopment of the property. The information requested is necessary for the MDEQ staff to prioritize your project and to obtain information required to determine project eligibility. Incomplete applications will cause delays in processing and potentially cause a property to be disqualified from the program. If your project qualifies, the MDEQ may request a kickoff meeting with you to define work expectations, sampling needs and timelines. If you have any questions, please contact Joseph Walczak, Brownfield Assessment Program Manager at 517-335-2151 or  HYPERLINK "mailto:walczakj@michigan.gov" walczakj@michigan.gov. Please submit the application and request letter by email to:  HYPERLINK "mailto:walczakj@michigan.gov" walczakj@michigan.gov Or by mail to: Joseph Walczak Michigan Department of Environmental Quality Remediation Division Superfund Section P.O. Box 30426 Lansing, MI 48909 SECTION 1 APPLICANT INFORMATION: 1. Provide the applicant and contact information. Applicant:  FORMTEXT       Address:  FORMTEXT       Contact Person:  FORMTEXT      , Title:  FORMTEXT       Address:  FORMTEXT       Telephone Number:  FORMTEXT       E-mail Address:  FORMTEXT       2. Provide the name of the project property for this application. Project property name:  FORMTEXT       SECTION 2  ELIGIBILITY: 3. Does the property meet the definition of  brownfield site as described in the federal Small Business Liability Relief and Brownfields Revitalization Act (Section 211(a)(39)(A) of the Public Law 107-118 (H.R. 2869))? If the property does not meet this definition, it is not an eligible property for an SSA. Yes  FORMCHECKBOX  The property is real property, the expansion, redevelopment, or reuse of which may be complicated by the presence or potential presence of a hazardous substance, pollutant, or contaminant. No  FORMCHECKBOX  STOP. 4. Does the property meet any of the following seven potential exclusions? If you check Yes to any of these exclusions, the property potentially may not be eligible for an SSA. Yes No  FORMCHECKBOX   FORMCHECKBOX  The property is a site listed or proposed for listing on the U.S. EPAs National Priorities List (NPL), a portion of an NPL site, or associated with an NPL site.  FORMCHECKBOX   FORMCHECKBOX  The property is subject to a planned or ongoing removal action under CERCLA.  FORMCHECKBOX   FORMCHECKBOX  The property is subject to unilateral administrative orders, court orders, administrative orders on consent, or judicial consent decrees issued or entered into by parties under CERCLA, the Solid Waste Disposal Act, the Federal Water Pollution Control Act, the Toxic Substances Control Act, or the Safe Drinking Water Act.  FORMCHECKBOX   FORMCHECKBOX  The property is subject to the jurisdiction, custody or control of the United States government.  FORMCHECKBOX   FORMCHECKBOX  The property is subject to corrective action under the Solid Waste Disposal Act and a corrective action permit or order has been issued or modified to require the implementation of corrective measures.  FORMCHECKBOX   FORMCHECKBOX  The property is a land disposal unit where a closure notification under subtitle C of the Solid Waste Disposal Act has been submitted and closure requirements have been specified in a closure plan or permit.  FORMCHECKBOX   FORMCHECKBOX  A portion of the property has had a release of polychlorinated biphenyls and the release is subject to remediation under the Toxic Substances Control Act. 5. Is the applicant a potentially responsible party that has caused or contributed to the contamination of the property to be assessed? If so, property potentially may not be eligible for an SSA. Yes  FORMCHECKBOX  Explain:  FORMTEXT       No  FORMCHECKBOX  6. Is the property an orphan property (any property for which there is no person liable for cleanup or remediation costs under 42 USC 9607 who has the ability to pay those costs). Yes  FORMCHECKBOX  Explain:  FORMTEXT       No  FORMCHECKBOX  Explain:  FORMTEXT       7. Does the applicant have or can it obtain access to 100% of the property to be assessed by MDEQ personnel? Yes  FORMCHECKBOX  Explain:  FORMTEXT       No  FORMCHECKBOX  Explain:  FORMTEXT       8. Has the applicant received in the past, is it currently receiving, or has it applied for federal brownfield assessment/cleanup funding for this property? Applied  FORMCHECKBOX  Year Applied:  FORMTEXT       If you received funding, for what year:  FORMTEXT       Amount Funded: $ FORMTEXT       Project Status:  FORMTEXT       Have not Applied:  FORMCHECKBOX  SECTION 3  PROPERTY DESCRIPTION 9. Provide the property name and any aliases or historic names.  FORMTEXT       10. Provide the street address of the property.  FORMTEXT      , and/or other property location information such as parcel number.  FORMTEXT       11. Provide the property geographical coordinates (latitude and longitude in either degrees/minutes/seconds or degrees.decimal degrees) and the point of measurement (center of property, entrance drive, etc.). Degrees-Minutes-Seconds Decimal Degrees Latitude:  FORMTEXT      o FORMTEXT        FORMTEXT       N or Latitude:  FORMTEXT      . FORMTEXT      oN Longitude:  FORMTEXT      o FORMTEXT        FORMTEXT       W Longitude:  FORMTEXT      . FORMTEXT      oW Measurement point (location):  FORMTEXT       12. Define the size of the property to be assessed:  FORMTEXT       acres 13. Provide the current property owner and contact information. Current Property Owner:  FORMTEXT       Type of ownership: Government  FORMCHECKBOX  Public Agency  FORMCHECKBOX  Private  FORMCHECKBOX  Address:  FORMTEXT       Telephone Number:  FORMTEXT       E-mail Address:  FORMTEXT       Contact Person:  FORMTEXT      , Title:  FORMTEXT       Address:  FORMTEXT       Telephone Number:  FORMTEXT       E-mail Address:  FORMTEXT       14. How did the current owner acquire the property? 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Purchase Price: $ FORMTEXT       Fair Market Value Price: $ FORMTEXT       15. Describe the historical and current uses of the property (if known). Historical:  FORMTEXT       Current:  FORMTEXT       16. Describe any potential hazards at the property, including any information from environmental, asbestos, or lead surveys that have been conducted (if known).  FORMTEXT       17. Please provide a map or photograph (electronic or hard copy) clearly delineating the boundaries of the property or portion of the property to be assessed in one of the following formats: A. A shapefile (ArcView ESRI) or Drawing Exchange Format file (dxf format AutoCAD) in a known coordinate system (denote system). B. A scanned image or hard copy boundary map with boundary dimensions showing the boundary displayed on top of an aerial photo or a USGS 7.5 minute topographic map. C. An image which contains a clearly delineated site boundary displayed on a plat map. SECTION 4 PROJECT DETAILS: 18. Does this site have a confirmed end user? Yes  FORMCHECKBOX  Explain:  FORMTEXT       No  FORMCHECKBOX  Explain:  FORMTEXT       19. Specify the proposed future use of the property.  FORMTEXT       20. Information gathered during the Site Specific Assessment will be used for: (Check all that apply.)  FORMCHECKBOX  Baseline Environmental Assessment and/or All Appropriate Inquiry (for release of liability from the MDEQ and the U.S. EPA, respectively.  FORMCHECKBOX  Redevelopment assessment and remedial clean-up decisions during redevelopment.  FORMCHECKBOX  Field screening for properties subject to other regulatory programs (RCRA, solid waste, etc.) to be used to determine eligibility or to prepare for the voluntary cleanup actions.  FORMCHECKBOX  Other (explain):  FORMTEXT       21. Have resources been expended on any assessment/redevelopment work at this property to spur property redevelopment. Include private investment and local, state and/or federal grants and loans? Yes  FORMCHECKBOX  Explain:  FORMTEXT     :|N|P|R|\|^|l|n||||||||||}}D}F}f}j}l}}}}}}}θΰθΓ{s{_θTh6hL@CJaJ&j($hv3ht!v>*CJUaJh"A^CJaJhL@CJaJhkICJaJhv3CJaJhkI>*CJaJ&j#hv3ht!v>*CJUaJh6CJaJ+jhv3h6>*CJUaJmHnHu jhv3h6>*CJUaJ&j<#hv3ht!v>*CJUaJhv3h6>*CJaJ}}}}}}}}}}}}}}0~h~~~~~~~~~~~~ȴԞԒzrjbrWCԞ&j%hv3ht!v>*CJUaJh6h6CJaJh"A^CJaJhWZCJaJh pCJaJhv3CJaJh CJaJh70CJaJhL@hL@>*CJaJ+jhv3h6>*CJUaJmHnHu&j$hv3ht!v>*CJUaJhv3h6>*CJaJ jhv3h6>*CJUaJh6CJaJhL@CJaJhL@hL@CJaJF}}}~~~~Bjl{ w ^`gd6 0^`0gdY$0^`0a$gdAj $^a$gdv3 0^`0gd p $^gd p $@@gd70 $@@gdkI H$@@gdL@~~~~~~~~~~~ (>@BDXZ\fhƲҜґvnvnvf^JҜ&j&hv3ht!v>*CJUaJh :0CJaJhWZCJaJhOCJaJhMFh pCJaJhv3CJaJhsiCJaJh6h pCJaJ+jhv3h6>*CJUaJmHnHu&j%hv3ht!v>*CJUaJhv3h6>*CJaJ jhv3h6>*CJUaJh6h6CJaJh pCJaJh p>*CJaJhjlnp!#biy{~ͽ͵qqbSbbGh :0B*CJaJphhv3h pB*CJaJphhv3h$9B*CJaJphhv3hB*CJaJphhv3hX5B*CJaJphhv3B*CJaJphhv3h'KB*CJaJphhMFh pCJaJhX5CJaJh6CJaJhv3CJaJhMFhX5CJaJh*CJaJȂʂւ؂ #$%mwxyzɺɺɍzqh\q\h\h\QhMFh(EpCJaJhYh(Ep5CJaJh*n:5CJaJha5CJaJhYCJaJhMFh ,CJaJhv3h pB*CJaJphhv3h'KB*CJaJphhv3hETTB*CJaJphhv3hMFB*CJaJphhv3h$9B*CJaJphh :0B*CJaJphh :0h :0B*CJaJphhv3B*CJaJphwxyƃǃxz ޅ 0^`0gd4: 0^`0gdB$gdB$^gd*CJaJ+jh*CJUaJmHnHu&j&h*CJUaJh*CJaJ jh*CJUaJhohoCJaJh ,CJaJhptCJaJ#jv&hy[phy[pCJUaJhy[pCJaJjhy[pCJUaJhMFh8CJaJhMFhzICJaJh*CJaJ+jh*CJUaJmHnHu&j'h*CJUaJh*CJaJ jh*CJUaJhohoCJaJh ,CJaJhptCJaJjhy[pCJUaJ#jb'hy[phy[pCJUaJ Vp܅ޅBYbf۹xldRlJh ,CJaJ#j(hy[phy[pCJUaJhy[pCJaJjhy[pCJUaJhMFh4:CJaJh4:CJaJhRCJaJhMFhB$CJaJhMFh$XCJaJh*CJaJ+jh*CJUaJmHnHu jh*CJUaJ&jN(h*CJUaJfjos{ÇćŇƇև褐v͐d\h*CJaJh ,CJaJ+jh*CJUaJmHnHu&j*h*CJUaJh*CJaJ jh*CJUaJht!vCJaJĉƉȉډ܉މ.026DFHJ^Ƶ}qf^LfƵ#j+hy[phy[pCJUaJhy[pCJaJhMFhxCJaJh ,hx>*CJaJU+jh*CJUaJmHnHu&j+h*CJUaJh*CJaJ jh*CJUaJht!vht!vCJaJh ,CJaJh'CJaJjhy[pCJUaJ#j+hy[phy[pCJUaJ  No  FORMCHECKBOX  Explain:  FORMTEXT       22. When do site assessment activities need to be performed?  FORMTEXT       SECTION 5  ADDITIONAL PROPERTY INFORMATION: 23. Has a Phase I Environmental Site Assessment been completed? Yes  FORMCHECKBOX  If yes, please submit a copy with this application. No  FORMCHECKBOX  24. Has a Phase II Environmental Site Assessment been completed? Yes  FORMCHECKBOX  If yes, please submit a copy with this application. No  FORMCHECKBOX  25. List and describe any known Recognized Environmental Conditions, areas of contamination, and contaminants of concern at the property.  FORMTEXT        SSAs are available through a task in the MDEQ s 128(a) Brownfield grant made possible by the federal Small Business Liability Relief and Brownfields Revitalization Act amendments to the Comprehensive Environmental Response Compensation and Liabilities Act (CERCLA).      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