SITE ELIGIBILITY APPLICATION: Please attach any completed environmental assessments, cost estimates, or environmental consultant’s remediation proposal outlining the scope of work. Attach a description of the intended reuse of the property after the remediation is complete.

Project name

Street address

APN

Describe property’s current use (commercial, residential, abandoned, unimproved, etc.)

Provide a brief history of the site’s past uses

Describe any previous environmental contamination on this site that has been remediated?

(including the removal of underground storage tanks)

What is the site presently zoned for?

Disclose what information specific to the site leads you to believe that environmental contamination needs remediation? (Please submit any completed environmental assessments or remediation plans for review)

Phase I completed by environmental consultant

Phase II completed by environmental consultant

Phase III completed by environmental consultant

Remedial action plan prepared by environmental consultant

Other:

Name of Environmental Consultant

Contact Person

Address

City State Zip

Telephone Fax Number

Is the site listed on a state or federal list of hazardous or contaminated sites? Yes No

If yes, disclose the list and contamination:

Is removal of the hazardous material required to be taken within six months? Yes No

Is there a water source on the site or within 100 feet of the site boundaries (e.g., pond, stream, wetland)? Yes No

If yes, describe the water source.

Is the site within a flood hazard area?Yes No

Has any government agency notified the applicant of any pollution or safety violations, citations, or enforcement actions at this or any other location? Yes No

If yes, provide the following information:

Date of Order

Agency Contact

Telephone Number

What was the resolution of the action?

Is any litigation pending or threatened, or which would affect the applicant’s ability to complete the project? Yes No

If yes, disclose the nature of the litigation:

Remediation Plan: (brief summary and cost estimates)

By signing below, the applicant certifies that:

  • The applicant has never been convicted of a felony or misdemeanor involving the regulation of hazardous materials;
  • The applicant has never been convicted of a felony or misdemeanor crimes involving moral turpitude, including, but not limited to, the crimes of fraud, bribery, the falsification of records, perjury, forgery, conspiracy, profiteering, or money laundering;
  • The applicant is not currently or ever have been a generator or transporter of contamination, or subject to any penalties resulting from environmental non-compliance at the subject site;
  • The applicant has never been suspended, debarred, or otherwise declared ineligible for funding or grants under any federal government program.

Business Name

By Date

Signature / Title

By Date

Signature / Title