Form Mo 780-1712 - Brownfields/voluntary Cleanup Program (Bvcp) Application Page 2
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4ASSESSMENT AND CLEANUP STATUS
Have any environmental site assessments, audits, sample collections or analyses been performed at the site?
Yes
No
If yes, please indicate below what site assessments have been performed:
Phase I
Phase II
Other __________________________________________________________________
Hazardous substances have been detected in:
Soil
Groundwater
Building
Not detected
Not sampled
Other ____________________
Has a remedial action plan been developed?
Yes
No
Has implementation of the plan begun?
Yes
No
Does not apply
Is the site now or has it ever been listed on CERCLIS?
Yes
No
If yes, indicate EPA CERCLIS identification number: _________________________________________________________________
Other identification numbers (i.e. EPA RCRA ID number, DERT County/Plant Number, etc.) __________________________________
___________________________________________________________________________________________________________
Is there/was there a registered underground tank on site?
Yes
No
If yes, give Petroleum Storage Tank Registration number if known: ______________________________________________________
REQUIRED DOCUMENTATION AND ENCLOSURES
Please enclose the following with this application:
• $200 application fee in the form of a check payable to the Missouri Department of Natural Resources.
• A copy of the warranty deed for the property, or, if not available, other documents giving the property legal description,
as approved by BVCP.
• Site map - A current U.S. Geological Survey 7.5 minute Quadrangle Map or street maps for urban areas.
• A completed DNR BVCP Consent for Access to Property form.
• Statement from PSTIF regarding eligibility.
• A brief narrative background statement giving history of manufacturing, commercial or other operations, and dates
and nature of activities that may have caused contamination.
• A narrative statement describing all known or suspected contaminant(s), contaminant sources and volumes present
on the property. Also indicate if other contaminants are suspected and estimate their volume(s) and source(s).
• Copies of all existing and relevant site assessment reports. A Phase I report should be submitted with your application
as a minimum. Please submit any photographs as originals or high-resolution color copies.
• A remedial action plan, if one has been prepared.
Please complete this application, sign in the appropriate space on page 3, and return, along with the above required
documentation and a non-refundable $200 application fee to:
Brownfields/Voluntary Cleanup Section
Hazardous Waste Program
Missouri Department of Natural Resources
or
P.O. Box 176
1738 E. Elm
Jefferson City, MO 65102-0176
Jefferson City, MO 65101
If you have questions, please contact the Brownfields/Voluntary Cleanup Section at (573) 526-8913.
MO 780-1712 (03-16)
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