Site-Specific Activities (SSA) Application State Response ...
FLORIDA DEPARMENT OF ENVIRONMENTAL PROTECTIONSiteSpecific Activities (SSA) ApplicationState Response Site ProgramFunded by CERCLA 128(a) GrantUse this application to request assistance for SSA such as a Targeted Brownfield Assessment (TBA), a Risk Assessment, and/or Limited Source Removals.APPLICANT INFORMATIONApplicant Organization:Address: FORMTEXT ?????City/State/Zip: FORMTEXT ?????Contact Person: FORMTEXT ?????Phone/Fax/Email: FORMTEXT ?????Describe Applicant’s Eligibility: FORMCHECKBOX Municipality/Local Government FORMCHECKBOX Non-Profit Organization FORMCHECKBOX Private Property FORMCHECKBOX Other FORMTEXT (Please specify) FORMCHECKBOX Citizen Affected By Potential SiteSITE INFORMATIONSite Name/Parcel:Site Address: FORMTEXT ?????City: FORMTEXT ?????Current Site Ownership:Name: FORMTEXT ?????Address: FORMTEXT ?????City/State/Zip: FORMTEXT ?????Phone/Fax/Email: FORMTEXT ?????Site Zoning: FORMTEXT ?????Total Acreage of Site: FORMTEXT ????? (attach a detailed site map)Number of Buildings on Site: FORMTEXT ?????Approx. Sq. Footage: FORMTEXT ?????Condition: (e.g., usable, partially razed, gutted by fire, etc.) FORMTEXT ?????Amount of Delinquent Property Taxes (if any) Value: FORMTEXT ?????If the applicant owns the property, please describe whether you are responsible for any of the environmental concerns at the site. FORMTEXT ?????Past Site Uses and Approximate Dates: (e.g., type of manufacturing, landfill, industrial, commercial, retail, etc.) Please Be Specific: FORMTEXT ?????Describe how the property became contaminated. FORMTEXT ?????Describe the nature and extent of the contamination. FORMTEXT ?????If the site is contaminated with petroleum, provide documentation of the following that:the site is of "relatively low risk" compared with other "petroleum-only" sites in the state;there is "no viable responsible party" legally capable of satisfying obligations under Federal or state law to assess, investigate, or clean up the site; funding for the site will be used by a party that is not potentially liable for the petroleum contamination to assess, investigate, or clean up the site; and the site is not subject to a corrective action order under the Resource Conservation and Recovery Act (RCRA).If the property is not owned by the applicant, does the applicant have plans for acquisition? Please describe those plans. FORMTEXT ?????If the applicant does not own the property, does applicant have legal permission authorizing the Department to enter the property to conduct site assessment activities? FORMCHECKBOX YesIf yes, please attach the Site Access Agreement form FORMCHECKBOX NoPlease Explain. FORMTEXT ?????Note: Failure to obtain legal permission for site access will result in delay of the applicationDescribe the anticipated flow of ownership of site/property throughout the process of assessment, cleanup, and redevelopment and describe any problems. FORMTEXT ?????ASSESSMENTDescribe prior site assessment activities. Please attach the assessment reports or at a minimum the “executive summary” and “conclusion” sections of report(s). FORMTEXT ?????Briefly describe any ongoing or anticipated involvement of federal, state, or local environmental regulatory agency as it relates to enforcement, assessment or cleanup activities of the candidate site. FORMTEXT ?????Is the site eligible for other or subject to state or federal regulatory programs? FORMCHECKBOX Yes FORMCHECKBOX No(i.e., Petroleum Cleanup Program, Drycleaning Cleanup Program, CERCLA, or RCRA)If Yes, Please Describe and Include Site or Facility Identification number. FORMTEXT ?????Describe site assessment activities being requested. FORMTEXT ?????Describe source removal/cleanup activities being requested. FORMTEXT ?????Describe the financial needs for each phase of the project (assessment, cleanup, and redevelopment), if known. FORMTEXT ?????REDEVELOPMENTAnticipated Future Use: (i.e. residential, recreational, commercial, retail, industrial, greenspace area) FORMTEXT ?????Describe applicant’s proposed vision for reuse. FORMTEXT ?????Describe municipal commitment such as financial incentives to encourage redevelopment (i.e., tax incentives, tax increment financing, fast-tracking permitting etc.). FORMTEXT ?????Describe proposed funding sources for any site cleanup and current or past evidence of developer interest. FORMTEXT ?????Identify committed funds (e.g., general revenues, Tax Increment Financing (TIF), staff time/inkind, grants). FORMTEXT ?????Please attach any supporting documents.How do proposed reuse(s) and your ongoing efforts to prevent the creation of future brownfields fit into your community's master plan, economic development plan/activities, other relevant plans/activities, and your ongoing efforts to redevelop brownfields? FORMTEXT ?????Describe the extent to which the grant would facilitate the creation of, preservation of, or addition to a park, greenway, undeveloped property, recreational property, or other property used for nonprofit purposes. FORMTEXT ?????Describe whether the project will use existing infrastructure (e.g., existing roads, rail/bus/subway services, buildings, utility services, sidewalks/pedestrian trails, recreational services, landscaping, neighborhood centers/institutions) or require its expansion. FORMTEXT ?????COMMUNITYProvide a detailed description of the target community that the project will benefit. Include demographic information and indicators such as the poverty rate, unemployment rate, special community situations (e.g., population size), or other environmental justice factors that support community need relating directly to this project (e.g., low-income and/or minority communities; sensitive populations, such as children and pregnant women; or communities disproportionately impacted by environmental factors). FORMTEXT ?????Explain how the targeted community will benefit. FORMTEXT ?????Describe how your plans for reuse of the site will enhance your community's social, economic, and environmental wellbeing? FORMTEXT ?????Describe how this project(s) will stimulate economic development while responding to community needs, including the creation of jobs, capital investment, and increases to the local tax base. FORMTEXT ?????Describe efforts to involve community organizations. FORMTEXT ?????Describe how affected communities will be involved in future land use and site ownership decisions. FORMTEXT ?????Describe any environmental justice concerns associated with the site. FORMTEXT ?????Describe citizen participation in project development and how the community will continue to participate in its implementation. FORMTEXT ?????Describe plans for ensuring that affected disadvantaged populations benefit environmentally and economically (directly or indirectly) from project activities and reuse. FORMTEXT ?????Describe other steps taken or planned, other than the brownfield project to achieve environmental quality in disadvantaged communities near the proposed project. FORMTEXT ?????LETTERS OF SUPPORTPlease provide letters of support for this Brownfield site selection.SUBMIT APPLICATION BY MAIL OR ELECTRONICALLY TOKelly Crain, Brownfields Program and Contract ManagerFlorida Department of Environmental ProtectionWaste Management DivisionWaste Cleanup Program2600 Blair Stone Rd., MS 4535Tallahassee, Florida 32399Phone: (850) 245-8953Kelly.Crain@dep.state.fl.us ................
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