Abandoned Tank Community Assistance Program State Form 49493 (8-99) Indiana Department of Environmental Management Office of Land Quality APPLICATION Community: Co-Applicant: Contact Person: Phone #: FAX #: Address: 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: American LegalNet, Inc. www.FormsWorkflow.com 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) American LegalNet, Inc. www.FormsWorkflow.com