Abandoned Tank Community Assistance Program
State Form 49493 (8-99)
Indiana Department of Environmental Management Office of Land Quality
APPLICATION
Community: Contact Person: Address: Co-Applicant: Phone #: FAX #: County:
Population of community where site located: Location of property for which assistance is sought:
Legal Description:
Number of tanks on the property: Previous property owner(s) (list name(s) and current address if known):
Please identify the owner who installed the tanks: Community obtained ownership of this property through: 9 Tax Delinquency 9 Lien 9 Condemnation 9 Other (Please explain) Current status of property Is the property abandoned? 9 Yes 9 No How many years has it been abandoned? If in use, for what purpose? (Please explain) What were the tanks used for? (i.e. gas station):
List any known spills, releases, fires and/or other problems at this site:
Have any environmental evaluations been conducted on this property? If so, please attach the appropriate data.
Discuss the future intended use of this property, potential for sale and/or redevelopment:
Community factors (What impact is there currently to nearby residences or businesses? If this site is selected for assistance, what will the future impacts be?):
Proposed community reciprocal project:
The applicant does hereby attest and certify that the information included in this assistance application is, to the best of their knowledge and belief, complete and accurate. By: Date: Signature & Title of person authorized to bind this political subdivision For IDEM use only: Net Assessed Value per Capita TANF Poverty Rate Indicator
State Form 49493 (8-99)