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Indiana Brownfields Program Comfort/Site Status Letter Request
State Form 51493 (R2/6-07) Indiana Finance Authority

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Return this form to: INDIANA BROWNFIELDS PROGRAM 100 N. Senate Avenue, Room 1275 Indianapolis, IN 46204 For questions: 317-234-1279 Submit form electronically to: [email protected] FAX: 317-234-1338

Pursuant to the Indiana Department of Environmental Management (IDEM) Nonrule Policy Document W-0051, "Brownfields Program Comfort and Site Status Letters Policy" (April 18, 2003), the Indiana Brownfields Program may issue a Comfort or Site Status Letter to stakeholders at brownfields sites that satisfy the eligibility criteria and conditions of the policy.

Brownfield Site Definition A brownfield site is defined as a parcel of real estate that is abandoned or inactive; or may not be operated at its appropriate use; and on which expansion or redevelopment is complicated because of the presence or potential presence of a hazardous substance, a contaminant, petroleum, or a petroleum product that poses a risk to human health and the environment. IC 13-11-2-19.3 Comfort Letter A Comfort Letter is issued to a party that qualifies for an applicable exemption to liability found in Indiana law or IDEM policy, but is not a legal release from liability. The Comfort Letter explains the applicable liability exemption or IDEM's exercise of enforcement discretion under an applicable IDEM policy. Potentially applicable liability exemptions or IDEM policies include: the Stakeholder is a government entity exempt from liability under IC 13-25-4-8(e), IC 13-11-2-150(c), or IC 1311-2-151(b); the Stakeholder is a creditor, lender, or fiduciary exempt from liability under IC 13-23-13-14, IC 13-24-1-10, or IC 13-25-4-8(c); the Stakeholder is not the statutory owner of an underground storage tank pursuant to IC 13-11-2-150(a) because the tanks were not used after November 8, 1984 and the Stakeholder was not the person who owned the tank immediately before the discontinuation of the tank's use; the Stakeholder is exempt from liability or eligible for a defense to liability as a bona fide prospective purchaser, contiguous property owner or innocent landowner pursuant to IC 13-25-4-8(b); and the Stakeholder satisfies the conditions of IDEM Nonrule Policy Document W-0047, "Property Containing Contaminated Aquifers" (20 IR 1674, January 30, 1997), or IDEM Nonrule Policy Document W-0038 "Property Containing Contaminated Aquifers/Underground Storage Tanks" (23 IR 2141, April 20, 2000). Site Status Letter A Site Status Letter is issued to a party that did not cause or contribute to or knowingly exacerbate the contamination and can demonstrate that current levels of contaminants of concern at the brownfield substantially meet current cleanup criteria as established by IDEM under the Risk Integrated System of Closure. The potential liability of the party requesting the letter is not addressed. The Site Status Letter states that based on a technical analysis of information submitted to IDEM pertaining to site conditions, IDEM concludes that current site conditions do not present a threat to human health or the environment and that IDEM does not plan to take or require a response action at the brownfield site.

INSTRUCTIONS: Please complete this form (type or print legibly) and return it to the Indiana Brownfields Program to begin the process of assessing eligibility to receive a letter. Each request will be reviewed by the Indiana Brownfields Program and IDEM staff. Determinations of eligibility are made based on facts and data provided with the request. A decision on whether or not to issue a Comfort or Site Status Letter will be made approximately 60 days from receipt of the request. The complexity of technical issues pertaining to site conditions may increase staff review time. Please attach any additional documentation required if space on the form does not allow for a complete response.

Contact Information
Letter Recipient Address: (number and street, city, state and ZIP code) Telephone Number Cell Number Fax Number E-mail Address Organization/Community

Environmental Consultant 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

Attorney Representing the Letter Recipient
Name(s) Address: (number and street, city, state and ZIP code) Firm

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 and 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 In Bankruptcy Abandoned Inactive Underutilized Tax delinquent Other (please specify) _________

Environmental Documentation Submitted for Review: (Check all that apply) Phase I Environmental Site Assessment-After 11/1/06 must comply with federal All Appropriate Inquiry Rule* Sampling Results Further Site Characterization Other (please specify) _______________________ *contact the Indiana Brownfields Program if you have questions The Site will be: Sold Leased Used by governmental entity Gifted Other (please specify) ____________________________ Undecided Phase II Environmental Site Assessment

Potential or intended reuse of property: (Check all that apply) Commercial Industrial Residential Mixed Use Park Green Space Other (please specify) ________________________ Undecided

Community Involvement/Public Participation: (Check all that apply) Community notification by news media Community input was not sought Public Meeting(s) Letter(s) of community support Community work group

How did you hear about the Indiana Brownfields Program? (Check all that apply) Indiana Brownfields Program staff, brochure, or web site Other State Program/Agency EPA Consultant Other (please specify) _________

Signature
I hereby request an Indiana Brownfields Program: Comfort Letter Site Status Letter

Signature of Letter Recipient or Authorized Representative

Date (month, day, year)