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Salem/Peabody Brownfield Coalition Revolving Loan Fund Page 1 STEP TWO– (This form must be submitted and redevelopment project approved by Salem/Peabody RLF Program before submitting application form Part II) Brownfield Redevelopment Project Funding Application – Part I Please contact Tom Devine at the Salem Department of Planning & Community Development at any time during the application process for guidance or information, at (978) 619‐5682 or [EMAIL REDACTED]. Send your completed Part I Application to: City of Salem Department of Planning & Community Development, 120 Washington Street, 3rd Floor, Salem, MA 01970, Attn: Tom Devine, Senior Planner. Date: Applicant/Borrower Information Applicant (Owners) Organization Mailing City: State: ZIP: Telephone number: Fax: Contact Person: Email: Form of Ownership: Corporation Limited Liability Corp. Partnership Proprietor Private Nonprofit Municipality Tax ID Date of Incorporation: Type of Business: Salem/Peabody Brownfield Coalition Revolving Loan Fund Program ---PAGE BREAK--- Salem/Peabody Brownfield Coalition Revolving Loan Fund Page 2 Site Information Address of site(s) to be cleaned up: Appx. site acreage: Date applicant obtained legal ownership of the property(ies): Method of acquisition (purchase, tax‐title, foreclosure, etc…): Assessor’s map & parcel number(s): Current property owner(s) (if other than applicant): Brief site history including current conditions and former owners and occupants: If property or building is on a federal, state or local historic register or if it is located within a designated historic district, identify the register and/or district: Date of completed Phase I Environmental Assessment: Date of completed Phase II Environmental Assessment: Date of completed Hazardous Building Materials Survey (if any): Name of firm(s) that completed Phase I/II Assessments/Hazardous Building Materials Survey(s): Name of Licensed Site Professional and license number: Brief description of type and extent of contamination at the site: Release Tracking Number(s) applicable to the site: Have any Activity and Use Limitations been placed on the property (as regulated under the MCP 310 CMR 40.0000)? [ ] Yes [ ] No If yes, attach a copy to this application. ---PAGE BREAK--- Salem/Peabody Brownfield Coalition Revolving Loan Fund Page 3 Has the site/property been audited under the MCP by the Massachusetts Department of Environmental Protection (MassDEP)? [ ] Yes [ ] No If yes, attach a copy of the Notice of Audit Findings and follow‐up correspondence. Cleanup Proposal and Loan/Subgrant Request Brief description of proposed cleanup strategy and intended post‐cleanup site use(s): Estimated cost of environmental cleanup: Source of above estimate: Other funding source(s) for cleanup: Amount being requested from the Salem/Peabody Brownfield Coalition RLF Program: If a consultant and/or contractor have already been procured to conduct the cleanup, describe the procurement process utilized and attached a copy of the procurement instrument (RFP, RFQ, IFB etc…): Borrower and Site Eligibility Provide the following information on clearly labeled separate sheets. a. Project Narrative including a site description, photo and map, evidence of site control (if not available, describe the schedule for obtaining it), current uses of any buildings, a site‐specific statement of all work proposed to be completed, and timeframe for cleanup activities (including estimated construction start and completion date); b. Plans for redevelopment of the site including the proposed reuse and redevelopment of the site, plan to achieve reuse and redevelopment objectives, and benefits (economic, environmental, health, and social) associated with the reuse and redevelopment of the site; and their compatibility with existing community plans, including local Master Plan. Must include letter of support from the municipality. ---PAGE BREAK--- Salem/Peabody Brownfield Coalition Revolving Loan Fund Page 4 c. Describe the cause(s) or source(s) of contamination, including the nature, amount, and location of hazardous materials, and the generator(s) of contamination d. Describe any previous EPA or DEP environmental non‐compliance history, including any past or present enforcement actions with respect to the site or the applicant e. Provide copies of the following documents: • Phase I and Phase II Environmental Site Assessment reports and (if applicable) Hazardous Building Materials Surveys • Site‐specific Quality Assurance Project Plan (QAPP) (if available*); • Site‐specific Health and Safety Plan (if available*); • An analysis of brownfields cleanup alternatives (ABCA) (if available*); • Estimate of cleanup costs; • Remedial design and engineering documents (if available*); and • Construction Plans (if available*). *If these documents are not available at the time of this application, it will be necessary to provide them at a later time in the loan process. f. Provide certification with respect to the following: • The site satisfies all EPA guidelines as an “eligible brownfields site”; • Applicant meets EPA’s “bona fide prospective purchaser” requirements; • Applicant has satisfied (or will satisfy) EPA’s “all appropriate inquiry” requirement prior to site acquisition; • Applicant has not been a generator or transporter of contamination at the brownfield site for which a loan is being requested; • Applicant does not have a familial or business relationship with the entity that caused or contributed to the contamination; • Applicant is neither currently nor has been subject to any penalties regarding environmental compliance, either from local, state, or federal authorities at the brownfield site for which a loan is being requested; • Applicant is not using the funds to pay for response costs at a site for which the applicant is potentially liable under 107 of CERCLA; • Applicant is authorized to enter into a loan and/or subgrant agreement (as applicable); • Applicant is not a Potentially Responsible Party under CERCLA for the subject site; ---PAGE BREAK--- Salem/Peabody Brownfield Coalition Revolving Loan Fund Page 5 • Applicant is not a party suspended or barred; • Recipient agrees to submit Quarterly Progress Reports to Salem/Peabody Brownfield Coalition RLF Program which documents the progress of cleanup activities and use of loan proceeds and subgrant; and • Recipient agrees to provide written notification both to the SPBC RLF Project Manager and to EPA of shipments of CERCLA waste to out‐of‐state disposal sites. • Applicant agrees to comply with all EPA Terms and Conditions • Applicant agrees to cooperate with Project Coordinator I, the applicant, hereby attest that the information contained herein is true and correct to the best of my knowledge. I understand that the Salem/Peabody Brownfield Coalition Revolving Loan Fund is funded through a grant from the U.S. Environmental Protection Agency. Should I receive a loan and/or subgrant through this program, I agree to comply with all applicable laws and the specific cleanup guidelines issued for my property by the U.S. Environmental Protection Agency and the Massachusetts Department of Environmental Protection. Signature: Date: Print Name & Title: