Form Mo 780-1712 - Brownfields/voluntary Cleanup Program (Bvcp) Application
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4STATE OF MISSOURI
DEPARTMENT OF NATURAL RESOURCES
BROWNFIELDS/VOLUNTARY CLEANUP PROGRAM (BVCP) APPLICATION
SITE LOCATION
SITE NAME
SITE ADDRESS (STREET, CITY, STATE, ZIP CODE)
COUNTY
SIZE OF SITE (ACRES)
U.S. CONGRESSIONAL DISTRICT
MO SENATE DISTRICT
MO HOUSE DISTRICT
TOWNSHIP, RANGE, SECTION
COORDINATES (UTM): NORTHING
EASTING
DATA SOURCE
PAST BUSINESS(ES) OPERATING AT THE SITE
PLEASE PROVIDE DRIVING DIRECTIONS TO SITE
BVCP APPLICANT INFORMATION
NAME
COMPANY
ADDRESS
PHONE
FAX
E-MAIL
RELATIONSHIP TO PROPERTY
OWNER
OPERATOR
PROSPECTIVE PURCHASER
OTHER _____________________
Owner information if Applicant is not owner:
NAME __________________________________________________
COMPANY __________________________________________________
ADDRESS _______________________________________________
TELEPHONE NUMBER _______________________________________
BILLING CONTACT
NAME
ADDRESS
PHONE
FAX
E-MAIL
TECHNICAL CONTACT (CONSULTANT, CONTRACTOR, ETC.) FOR CLEANUP RELATED ISSUES
NAME
ADDRESS
PHONE
FAX
E-MAIL
ELIGIBILITY CRITERIA
YES
NO
UNKNOWN
1. Do current site conditions constitute an imminent and substantial threat to public health or the
environment? (Is the site under an emergency declaration by MDNR or the EPA?)
2. Is, or was, the site, or any part thereof, a permitted or interim status hazardous waste management facil-
ity regulated under the Resource Conservation and Recovery Act (RCRA)?
3. Has the site, or any part thereof, been investigated for listing on the Superfund National Priorities List?
4. Is, or was the site, or any part thereof, the subject of an enforcement action, or does the site warrant an
enforcement action under RCRA; Comprehensive Environmental Response, Compensation and
Liability Act (CERCLA); the Missouri Hazardous Waste Management Law, or any other federal or state
environmental law or statute?
5. Has remediation been conducted at the site?
6. Is or was the site or any part thereof, eligible for Petroleum Storage Tank Insurance Fund (PSTIF)?
If you answered “yes” to any of the above questions, the site may not be eligible for cleanup under the BVCP.
Check here if an application is planned or has been made to the Missouri Brownfield Redevelopment Program for this site.
MO 780-1712 (03-16)
PAGE 1 OF 3
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