Brownfield Inventory Submittal Form

The Kentucky Brownfield Program Recycling the Commonwealth

General Site Information

County: Address: Property Acreage: Zoning: Sale Price:

Latitude (if known):

Longitude (if known): Lat/Long Collection Method:

Building/ Property Specifics

Current Use:

Past Use:

Building Use Stories Sq. Footage Construction Condition* 1 2 3 4 5

If there are more than 5 buildings on the property please list them and the site descriptions on a separate sheet of paper.

* Rating System with examples of typical condition 5- Ready for occupancy 4- Needs mostly cosmetic work 3- Appears structurally sound, but has limited water, fire, vandalism, or similar damage 2- Appears structurally sound, but has significant water, fire, vandalism or similar damage 1- Part or all of the building appears to have significant structural damage Transportation

Nearest Interstate: Distance to Interstate: Nearest Airport: Distance to Airport: Rail Access: Water/ Port Access:

Utilities

Utility Services Available Provider Municipal Yes No Water Gas Yes No Electric Yes No Service Sewer Sewer Septic Unknown Type Broadband Yes No

Environmental Information

Status of investigation:

Known or suspected contamination:

Status of Remediation:

Existing environmental or institutional controls: Contact Information

Contact: Company or Agency: Mailing Address: Phone: E-mail:

Additional Information

If available, please attach photographs and maps of your site. Electronic media or CD-ROMs are encouraged.

Application Submittal Instructions

Please mail this form to:

The Kentucky Brownfield Program 300 Fair Oaks Ln. Frankfort, KY 40601 or

Send via e-mail: [email protected] or

Fax to: The Kentucky Brownfield Program at 502-564-9720