Email Brownfield Information Request Form This form is used as a pre-screening tool for our Brownfield Administrator. The administrator will contact you for more information. First Name * Last Name * Email Address * Address of Property * City * State * Zip * Phone Number * Are you the current owner? * Yes No Did you generate any hazardous materials on the property? * Yes No What is the current status of the property (vacant, in use)? * What is the age of the building(s)? * What is the size of the building(s) and how many floors on the property? * What are the primary environmental concerns on the property? * What is the previous use of the property? * What is the size of the lot? * Is the property tax delinquent? * Yes No Is a map, aerial photo, or other illustration that shows the outline of the property and its boundaries available? * Yes No Were there any past environmental reports and/or response actions associated with the property? * Yes No Are there any other contamination concerns including Asbestos and Lead-Based paint? * Yes No Is there physical access to the property? * Yes No Is there a critical deadline or suspense date for completing the assessment? * Yes No What is the proposed reuse/redevelopment of the property? Please describe in detail. * If a prospective buyer, please list the name of current owner and date purchased by current owner. *