Brownfield Application | Headwaters RC&D

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BROWNFIELDS PROGRAM Application

Questions about this form? Please Contact:

Melissa Wanamaker

Headwaters RC&D

Brownfields Manager

mwanamaker@headwatersrcd.org

(406) 533-6781

Application for Headwaters Brownfields Funding Assistance for Clean Up Community Grant and Revolving Loan Fund

Project Name

Brief Description of the Project (1500 Characters or Less):

Is your project in the Headwaters region? *

Yes

No (projects outside of the region are not eligible)

If yes, which county?

Site Address or Geocode

Applicant's First name

Applicants Last name

Phone

Email

Applicant's Legal Structure *

State, County or Local Government

Non-profit organization

Individual

For-profit company

Is the property owned by the applicant? *

Yes

No

If no, list owner's name:

If no, list owner's legal structure *

State, county or local government

Non-profit organization

Individual

For-profit company

Date acquired by owner (if known):

How was the property aquired by the owner (if known):

Purchase

Tax Deed (non-payment of taxes)

Gift/Inheritance

Other (explain below)

Unknown

If other above, please explain:

Explain how the property was contaminated (if known):

Has a responsible party been identified?

Yes

No

Unknown

Is the owner of the property potentially liable for the contamination?

Yes

No

Unknown

Is the property subject to litigation?

Yes

No

Unknown

If yes, please explain:

Is the property the subject of a DEQ/EPA administrative order, a court order, or violation?

Yes

No

Unknown

If yes, please explain:

Has redevelopment or reuse been complicated by the contamination?

Yes

No

Unknown

If yes, please explain:

Proposed Redevelopment (use of property after cleanup):

Is there a community benefit to the clean up? Who will benefit?

Will a direct health or environmental threat be mitigated by this action?

Will energy efficiencies result from this funding?

Has an environmental assessment been conducted?

Yes

No

Unknown

If not, we may be able to connect you to no-cost assessment assistance through our partners at EPA or DEQ. If yes, specify level:

All Appropriate Inquiry (Phase 1 Assessment)

Phase 2 Assessment

Identification of clean up options and costs

Other

Contamination verified (check all that apply):

Asbestos

Lead Paint

Petroleum Products

Methamphetamine

PCB

Other Hazardous Chemicals

Estimated Cost of Cleanup:

Funding provided by applicant:

Funding from other sources:

Loan requested from Headwaters RD&C:

Grant requested from Headwaters RD&C (only available to non-profits or municipalities):

Person completing application:

Title:

Today's Date

Your Signature

Please attach any photos & assessment data you may have. Non-profit applicants seeking grant funding should also attach: IRS Non-Profit Determination Letter, List of Board of Directors, Most recent annual financial statement, Most recent 990 Tax Return, and Articles of Incorporation. Attachments can also be emailed to Melissa Wanamaker at: mwanamaker@headwatersrcd.org

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Phone: (406)723-4349

info@headwatersrcd.org

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