State Form 49493 - Abandoned Tank Community Assistance Program - Office Of Land Quality Of Indiana Department Of Environmental Management Page 2

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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)

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