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Environmental Consultant Representing the Letter Recipient Firm Name(s) Address:(number and street,city,state and ZIP code) Telephone Number Cell Number Fax Number E-mail Address Attorney Representing the Letter Recipient Name(s) Firm Address:(number and street,city,state and ZIP code) Telephone Number Cell Number Fax Number E-mail Address Site Information Site or Project Name(s) Address:(number and street,city,state and ZIP code) IDEM Site Number US EPA Site Number Size In acres Current Owner Address:(number end street,city,state and ZIP code) Telephone Number Cell Number E-mail Address Property Status Current Status:(Check all that apply) ❑Private Owner ❑Public Owner Din Bankruptcy ['Abandoned['Inactive ❑Underulilized ❑Tax delinquent ❑Other(please specify) Environmental Documentation Submitted for Review:(Check all that apply) ['Phase I Environmental Site Assessment-After 1111106 must comply with federal All Appropriate Inquiry Rule'['Phase II Environmental Site Assessment ['Sampling Results ❑Further Site Characterization ['Other(please specify) 'contact the Indiana Brawnfields Program If you have questions The Site will be: ❑Sold ❑Leased ['Used by governmental entity OGifted ❑Other(please specify) __ ❑Undecided Potential or intended reuse of properly:(Check all that apply) ❑Commercial['Industrial['Residential[Nixed Use❑Park❑Green Space❑Other(please specify) ❑Undecided Community Involvement/Public Participation:(Check aft that apply) ['Community notification by news media ❑Public Meeting(s)❑Letter(s)of community support ['Community work group ['Community input was not sought How did you hear about the Indiana Brownfletds Program?(Check at that apply) ❑Indiana Brownfieids Program staff,brochure,or web site ❑Other State Program/Agency ❑EPA ❑Consultant ❑Other(please specify) Signature I hereby request an Indiana Brownflolds Program: ['Comfort Letter ❑Site Status Letter Signature of Letter Recipient or Authorized Representative Date(month,day,year)