Consent for Access to Property for the U.S. Environmental Protection Agency Targeted Brownfields Assessment

U. S. ENVIRONMENTAL PROTECTION AGENCY
"E REGION 7

Use only for Properties within Region 7 ^

Iowa, Kansas, Missouri, Nebraska, and Tribal Lands %L PRa^

bordered by these states

Consent for Access to Property for the U.S. Environmental Protection Agency

Targeted Brownfields Assessment

As an applicant to the U.S. Environmental Protection Agency (EPA) Targeted Brownfields Assessment
(TBA) program, EPA requires site access to perform the requested Phase I and Phase II Environmental
Site Assessments (ESA). As such, EPA requires the signature of the property owner on the attached
Consent for Access to Property form. Your TBA application will be considered complete and ready
for EPA review once EPA receives the signed Consent for Access to Property form.

Below is a brief description of Phase I and Phase II site assessments. Environmental assessment work
would be carried out by EPA's authorized representatives, Toeroek Associates, Inc. and/or Tetra
Tech, Inc. If you have questions, please contact Sandeep Mehta at 913-551-7763 or
Mehta.Sandeep@epa.gov.

TBA Background and General Scope of Phase I and Phase II Work

EPA's TBA program helps states, tribes, and municipalities minimize the uncertainties of contamination
often associated with brownfield sites. This program supplements other efforts under the Brownfields
Program to promote the cleanup and redevelopment of brownfield sites. TBAs are conducted by an EPA
contractor on behalf of an eligible entity. Services include site assessments, cleanup options and cost
estimates, and community outreach.

A TBA may encompass one or more of the following activities:

• An ASTM Phase I environmental site assessment, which includes a background and
historical investigation and site inspection;

• An ASTM Phase II full environmental site assessment, which includes sampling activities
to identify types and concentrations of contaminants and the areas of contamination;

• A Hazardous Material Survey, which includes an inspection for presence of asbestos-containing
building materials, chlorinated biphenyls in caulk, and lead-based paint; and

• The determination of how much more investigation is needed and/or the establishment of
cleanup options and cost estimates based on future uses and redevelopment plans.

TBAs are considered a grant of services and are conducted by environmental consultants currently under
contract with EPA. It is also important to note that the TBA program does not provide assistance to
conduct site cleanup or building demolition activities.

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NE

KS MO

IA

CONSENT for ACCESS to PROPERTY for

Targeted Brownfields Assessment
Tribal Entity

Property Owner(s)/Tenant(s):

Property Description:

Site Property Address

Street Address:	

City, State, Zip Code:	

Assessor's Parcel Number:	

Right of Entry: I am the owner, representative of the owner, or tenant of the Property described

above. I hereby consent to and authorize the	, the United States

Environmental Protection Agency, and the	, and their

representatives, employees, agents and contractors (collectively, Agencies) to enter upon such
Property, and perform and carry out Phase I and II Environmental Assessments pursuant to the
Comprehensive Environmental Response, Compensation and Liability Act of 1980 (CERCLA),
42 U.S.C. Sections 9601-9675. The duration of TBA related activities shall be determined and
agreed upon before initiation of work with anticipation of work being completed within a year.

Scope of Access:

A.	I consent to provide the Agencies access to the above-described Property for the purpose
of performing environmental assessments, including obtaining samples (soil, subsurface
soil, air, water, groundwater and other substances) and locating utilities and/or equipment
on the Property in preparation for, and in the course of, such environmental assessments.

B.	I agree not to take any actions with respect to the property that might endanger the quality
of the samples or the health and safety of any person taking such samples.

C.	I will receive at least forty-eight hours notice of the necessity to take any follow up samples.
I will not unreasonably withhold consent for such additional sampling.

D.

All material and equipment utilized by the Agencies will be removed from the Property
upon the completion of the environmental assessment activities authorized hereunder and
that the Property will be restored as nearly as reasonable to its original state and condition

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existing immediately preceding the beginning of activities set forth in this consent form,
provided that if any monitoring wells are required they may be left on the Property until
the need for the same no longer exists, whereupon the Agencies may abandon the
monitoring wells by capping or other approved methods. I consent to provide the
Agencies access to such monitoring wells beyond the term of this consent form as
necessary to take additional samples and to maintain the monitoring wells.

5. Term of Consent: This consent granted hereby will terminate within one year of my execution of
this consent form

I have read this consent form and understand that it grants permission to the

	in	, the United States Environmental Protection Agency, and

the	, and their representatives, employees, contractors,

and agents, to enter the above-described Property for purposes of conducting the environmental
assessment activities and agree to its terms and conditions. I have given this written permission
voluntarily and without threats or promises of any kind. By my signature I acknowledge that I am
authorized to grant the access provided for herein.

Property Owner Signature:	

Property Owner Printed Name:	

Date:	

Phone Number:	

Email Address:	

Name of EPA Targeted Brownfields Assessment Applicant:

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