Application Packets for Real Property for Public Health Purposes

Form Approved

OMB No. 0937-0191

Exp. Date XX/XX/20XX

APPLICATION

INSTRUCTION BOOKLET

For The

Department of Health & Human Services

Federal Property Assistance Program

public health

Program Support Center

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0937-0191 . The time required to complete this information collection is estimated to average 200 hours/ minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 336-E, Washington D.C. 20201, Attention: PRA Reports Clearance Officer

Table of Contents

Program Conditions Subsequent to Conveyance 3

List of Eligible Health Programs 4

Criteria For Application Review 5

Application Instructions 6

Application Checklist 7

Application Format 8

Identification of Applicant 8

Organizational Eligibility of Applicant 8

Description of Real Property Requested 9

Services Applicant plans to offer 9

Experience of the Applicant 10

Need for Services Offered by Applicant 10

Utilization of the Property by Applicant 11

Ability to Finance and Operate 11

Local Government Notification and Local Land Use Plans 12

Instructions for Attachments A, B and C 12

Certification of Veracity and Understanding of assignment authority 13

Attachment A: Applicant Certification 14

Attachment B: Resolution to acquire Property 15

Attachment C: Environmental Questionnaire 17

Attachment D: protection and maintenance standards 22

Program Conditions Subsequent to Conveyance

Transfers of real property are generally made by quitclaim deed, and are subject to the following conditions which are contained in the conveyance instrument:

1. Grantee must utilize the property in accordance with their approved application for a period of thirty (30) years from the date of the initial deed.

2. Where construction or major renovation is not required or proposed, the Property must be placed into use within twelve (12) months from the date of the deed. Where construction or major renovation is contemplated at the time of transfer, the Property must be placed into use within thirty-six (36) months from the date of the deed.

3. Grantee may not sell, lease, sublease, or otherwise encumber the property without prior written consent of the grantor.

4. Grantee must submit annual utilization reports coinciding with the anniversary date of the deed.

5. Grantee must comply with section 606 of the Federal Property and Administrative Services Act of 1949; the Fair Housing Act (42 U.S.C. § 3601-19) and implementing regulations; and as applicable, Executive Order 11063 (Equal Opportunity in Housing) and implementing regulations; Title VI of the Civil Rights Act of 1964 (42 U.S.C. § 2000d to d-4) (Nondiscrimination in Federal Assisted Programs) and implementing regulations; Title IX of the Education Amendments of 1972 (20 U.S.C. § 1681) and implementing regulations; the prohibitions against discrimination on the basis of age under the Age Discrimination Act of 1975 (42 U.S.C. § 6101-07) and implementing regulations; and the prohibitions against otherwise qualified individuals with handicaps under Section 504 of the Rehabilitation Act of 1973 (29 U.S.C. § 794); the Architectural Barriers Act Accessibility Standards (ABAAS) (36 C.F.R. 1191, Appendices C and D); and all other implementing regulations for the above listed statutes, including all requirements imposed by or pursuant to the regulations of the Grantor (45 CFR Parts 12, 80, 84 and 91) issued pursuant to said Acts and now in effect.

6. Grantee must remain tax supported or a nonprofit tax-exempt organization under section 501(c)(3) of the IRS code of 1986 throughout the period of restrictions.

Upon breach of any of the conditions subsequent contained in the deed of conveyance, title may revert to the Government. The grantee may also be permitted to abrogate the conditions by:

1. Obtaining the consent of the grantor, or its successor in function, and

2. Making payment to the United States of America of 1/360th of the percentage public benefit allowance granted of the fair market value as of the date of such requested abrogation, exclusive of the value of improvements made by the grantee to the extent that they add to the value of that portion of the Property to be released, for each month of the period to be abrogated.

If utilization of the property has not commenced within 12 months or 36 months where construction or major renovation is contemplated, payments will be required for each month of the non-use thereafter.

NOTE: Other covenants and conditions may be required in the conveyance instrument for such concerns as lead-based paint, environmental condition of the property, historical preservation issues, etc.

List of Eligible health Programs

The following is a list of the common types of programs considered eligible for real property grants. It is only a partial listing. Additional health programs not listed may also be eligible.

1. Medical institutions

2. Hospitals

3. Health centers (i.e., related laboratories, administrative offices, and public health nursing

programs)

4. Mental health centers

5. Clinics

6. Nursing homes (i.e., long term care and convalescent facilities)

7. Medical, dental, nursing, and paramedic schools

8. Infirmaries

9. Diagnostic or treatment centers providing outpatient services and care

10. Preventive medical/health care programs

11. Rehabilitation centers for mentally or physically disabled persons which provide an integrated

medical, psychological, social evaluation and training program

12. Residencies for physicians, nurses, paramedics, etc. in isolated areas

13. Pollution and pest control (related to public health)

14. Maternal and child health programs

15. Mental and physical hygiene training programs

16. Sanitary engineering and inspection

17. Health and nutrition education

18. Drug and alcohol abuse rehabilitation programs

19. Juvenile delinquent rehabilitation, diagnostic, and evaluation programs

20. Communicable and chronic disease control (i.e., immunization programs)

21. Migrant and Native American health programs

22. Sewage disposal systems

23. Storm sewer systems

24. Solid waste programs (i.e., sanitary landfills, incinerators, and recycling facilities)

25. Water systems (i.e., wells, pumps, underground distribution mains, purifiers, reservoirs, water towers,

and protected watershed properties)

26. Paramedic emergency treatment programs

27. Health administrative offices

28. Animal control facilities

29. Forensic laboratories and morgues

Criteria For Application review

Applications are evaluated on the basis of the following factors:

A. Organization Eligibility – The eligibility of an organization to receive a transfer of Federal surplus property pursuant to 45 C.F.R. § 12.3(b).

B. Services Offered – The extent and range of proposed services. See the list of eligible programs on page four.

3. Experience – Demonstrated prior success in operating similar programs and recommendations

attesting to that fact by local, State, and Federal authorities.

3. Need – The demand for the program of use proposed by applicant.

E. Utilization – The degree to which the available property will be fully utilized under applicant’s proposed program of use.

1. Fully utilized includes making the best use of the entire property and any existing or proposed structures.

2. If a proposed program does not use the entire property, applicants can include plans to rent portions of the property to other eligible entities for approvable programs. The name and eligibility of the other entities must be included in the application along with written documentation of an agreement to rent portions of the property for an approvable program.

F. Financial Ability – The adequacy of funding that will likely be available to run the program fully and properly and to operate the facility.

7. Implementation Time – The amount of time necessary for the proposed program to become operational. Please note that all deeds include a clause that requires full utilization of the property within twelve (12) months from the date of the deed, unless major construction/renovation is required, in which case the applicant would have thirty-six (36) months from the date of the deed.

7. Licensure, Accreditation, and Environmental Compliance

Application Instructions

Real Property Program

For Public Health Purposes

(ON SITE)

Please provide complete responses to each numbered item in the application format. For ease of reference, begin each response with its respective item number and heading. In an instance where a request for information is not applicable to your program, please include the heading and state “Not Applicable.” A good presentation of an application reflects a well thought out plan and objective for the property.

You must submit an original and two (2) copies of the application, along with all attachments.

Applications determined incomplete will either result in a disapproval of the application or a request for additional information. However, it is the responsibility of the applicant to ensure that all information requested in the application is presented in a detailed and complete manner.

Submit completed applications to the Department of Health and Human Services’ (HHS) office, listed below, by the date specified in the accompanying transmittal letter. If the applicant cannot meet this date, HHS will consider requests for extensions.

Federal Property Assistance Program

Program Support Center

Room 12-07, Parklawn Building

5600 Fishers Lane

Rockville, Maryland 20857

If you have any difficulties with the application, or have other questions or concerns, please contact a Realty Specialist at (301) 443-2265 or rpb@psc.hhs.gov.

Application Checklist

Please use the following checklist to ensure that your application is complete before sending it to HHS. If HHS finds an application to be incomplete, HHS may deny the application.

1. Provide a detailed response to items I-VIII of the application

2. Notify all appropriate units of local government

3. Certify veracity of application and understanding of assignment authority by signing item XI of the application

4. Attach all requested documents, along with any other documents the applicant feels will present a more complete understanding of the proposed use of the property

5. Certify applicant’s compliance with applicable Federal laws, insurance requirements, and protection and maintenance standards of the property by signing Attachment A

6. Complete and sign the Resolution to Acquire Property in Attachment B

7. Complete and certify the Environmental Questionnaire in Attachment C, and provide copies of of all relevant documentation

8. Provide one original and two copies of the completed application, including all requested attachments

Application Format

Use the following format to complete your application. Include any supporting documentation as attachments.

• At the top of the first page, state the official name and address of the Federal installation where the surplus property is located (city, county, and State), and the GSA and/or landholding agency number assigned to the property.

• Put the GSA and/or landholding agency number assigned to the property at the top of each additional page.

1. Identification of Applicant

1. State the legal name of the applicant organization.

2. Give the name, title, and address of the person authorized to complete this purchase. The

authorized representative must be the same as named in the governing board resolution.

3. Give the address and telephone number of applicant organization.

2. Organizational Eligibility of Applicant

1. State whether the applicant is a State, political subdivision or instrumentality of a State,

or a private nonprofit organization, tax-exempt under section 501(c) (3) of the

Internal Revenue Code of 1986, as amended. If tax exempt, include a copy of the formal exemption letter from the Internal Revenue Service.

2. Provide a copy of the document showing statutory or other authority under which your

organization is permitted to acquire and hold title to real property for the proposed use.

A copy of the applicable citation from the Corporations Division of the Secretary of

State=s Office, where the applicant is registered, will satisfy this requirement. If the

applicant is a nonprofit corporation, present evidence showing said corporation’s authorization, under its charter, to hold title to the real estate for which it has applied. Provide a copy of the charter and State certification with the application.

3. Identify all possible lessees, sub-organizations, affiliates, etc., that may participate in

and/or operate the proposed program on the requested property.

1. Any entities listed above must satisfy the same eligibility requirement mentioned in

A and B of this section. Provide documentation as necessary.

2. If any of the above entities will be paying rent to the applicant, provide a draft

agreement detailing the rental terms, including the amount to be charged. Rent cannot exceed the cost of utilities and maintenance for the space used by the lessee.

3. Provide commitment letters, memorandums of agreement, or any other

documentation detailing the planned cooperation between the applicant and all

entities listed above.

4. Indicate whether the applicant organization is accredited, approved, or licensed by

Federal or State accrediting, approving, or licensing authority. If so, give the name of such authority and provide documentation.

3. Description of Real Property Requested

1. Give a general description of the property being requested. The description should

include the amount of acreage and improvements, e.g., buildings, structures, etc. Identify

buildings as follows:

Building No. _____________________________________________

Building Name ___________________________________________

Size (square feet) _________________________________________

Please be advised that the amount of property requested should not exceed operating requirements.

NOTE: A legal description is not required at this time, but may be requested at a future

date.

2. Give information for items (1), (2), (3) and (4) as applicable:

1. Indicate any zoning/land use regulations that are applicable to the subject property,

and assure that the proposed program will conform to such regulations.

2. State that the renovation of existing buildings (if any), or construction of any new

structures, will meet State and local building codes and/or regulations for the proposed program of use.

3. Report the exact description of utilities required and state how arrangements will be

made for securing all needed utility services.

4. Identify any easements, including overhead and underground, which are reported

with the property, or are to be otherwise acquired for use in connection with the

property.

2. Related personal property included with the available real property may generally be

acquired if the need and use are specifically included and justified in the application. It is subject to the same discount allowance as the real property for which you have applied. Such related personal property is to be identified by an inventory attached to each copy of the application showing the description, serial number, or other adequate identification. This information may be obtained from the landholding and/or disposal agency.

4. Services Applicant Plans to Offer

1. Identify the services the applicant will provide through the use of surplus Federal

property. Please provide a specific and detailed account.

5. Experience of the Applicant

1. Demonstrate that the applicant is qualified to implement the program of use. Provide a

description of:

1. The full range of services currently provided by applicant and the length of time any

current programs have been operating;

2. The organization’s present staff in terms of numbers and qualifications;

3. The proposed level of staffing and qualifications of such staff as needed for the

proposed program; and

4. Past experience and demonstrated success of the applicant relevant to the proposed

program.

B. Identify whether the services proposed by the applicant are similar in scope to those currently being offered by applicant. If proposed services are greater or different than services currently offered by applicant, how does applicant intend to account for this gap in experience?

C. If possible, please provide written recommendations, endorsements, and studies from appropriate State agencies, public officials of State and local governments, and recognized national or local sponsoring associations or organizations, attesting to the successful operation of your organization.

6. Need for Services Offered by Applicant

1. Identify the need for the services the applicant will provide through the use of surplus

Federal property. Indicate the service area (city, county, etc.), population

to be served, and an estimation of the number of public health clients to be served

annually after full utilization.

B. List other facilities in the service area that currently offer the same type of service you

propose to offer, including the number of clients and/or beds. Provide information to

support the need for additional services in the service area. Include any surveys, reports,

or documentation to support your analysis.

3. If need stems from an emergency resulting from a disaster, explain fully.

3. If need is a result of requirements to comply with State standards, explain and enclose

certifications from appropriate State departments (i.e., State statutes, court decisions, etc.).

3. Identify any real estate owned or leased by the applicant organization. If applicable,

include a statement that the real estate owned or leased by the applicant organization is not suitable for the proposed program of utilization.

7. Utilization of the Property by Applicant

1. Submit a rough draft plat of the entire property, including:

   1. The nature and location of existing improvements and details of any proposed

renovations;

2. The location of proposed services within the building;

3. The estimated square-footage use of each component of the proposed program; and

4. The location, type, size, and proposed use of any new structures to be built on the

property.

2. Describe the time required for completion of improvements and for bringing the property

to full utilization. Please note that an applicant must place the property into its proposed use within twelve (12) months from the date of transfer, or thirty-six (36) months where new construction or major renovations are required. If the applicable time limitation is not met, the transferee shall either commence payments in cash to HHS for each month thereafter during which the proposed use is not implemented or take such action as set forth in § 45 C.F.R. 12.12 as is deemed appropriate by the Department.

NOTE: Any future improvements or renovations to the requested property planned for an unknown future date after the property is in use, unless detailed in full including proposed plans and a cost estimate in this application, are considered speculative and must receive prior approval from HHS prior to commencing construction.

8. Ability to Finance and Operate

1. Detail the estimated costs anticipated to prepare the property for full utilization,

including:

1. Renovations to existing facilities;

2. Construction of new facilities; and

3. Changes to the landscape (e.g. parking, recreational, open space).

B. Detail the estimated costs anticipated to operate the program, including any maintenance costs.

C. Give a full and complete statement of the ability to finance, operate, and maintain the

property requested. Identify the source of funding for converting the property for its intended use, including any new improvements. Funding sources for program operations should be identified separately. Be sure to include the capital outlay budget and the following, if applicable:

1. Special building funds;

2. Undistributed reserve;

3. Property tax rate;

4. Funds available for personnel and maintenance;

5. Amount raised by taxation;

6. State appropriation; and

7. Other (contracts, services, federal payments, fund-raisers, grants, etc.).

D. If the applicant contemplates that major construction/renovation is necessary to make the

property suitable for full utilization and funds are not currently available, give plans and proposed sources of funding to carry out the proposed program and development. Please include the estimated amount of funds to be obtained from each source.

8. Local Government Notification and Local Land Use Plans

A. The applicant must provide written notification, of its proposed program, to the

applicable unit of local government responsible for providing sewer, water, police, and fire services. Please provide copies of these notices.

2. State that the property is suitable for the proposed use and/or provide plans for its

conversion. If there are any easements, rights of use, zoning regulations, or other encumbrances, existing or proposed, which would impede the public health program, please identify.

8. Instructions for Attachments A, B, and C

1. The applicant must certify, by signature of Attachment A, its assurance of compliance

with nondiscrimination, insurance, and protection and maintenance requirements. Please

provide a signed copy with the original and each copy of the application.

2. Complete the governing board resolution, enclosed as Attachment B, authorizing a

representative to act on behalf of the applicant organization. Please note that the certifying officer must be an official other than the representative named in the Resolution.

C. The National Environmental Policy Act of 1969 (P.L. 91-190 42 U.S.C. Sections 4321-

4347) requires consideration of the environmental effects that may result from major Federal actions significantly affecting the quality of the human environment, including real property conveyances. Your completion of Attachment C will assist us in evaluating any potential environmental effects arising from your proposal. You are required to provide the documentation supporting your questionnaire responses.

XI. Certification of Veracity and Understanding of Assignment Authority

I, ______________________________________, certify that the information in this

^{(Name of authorized official)}

application is true, accurate and complete to the best of my knowledge. Additionally, I

understand that the Department of Health and Human Services’ (HHS’) approval of this

application does not constitute the final decision on whether to transfer the property, rather,

authority to assign the property for transfer rests with the disposal agency, not HHS.

_______________________________________________________________

Name of Applicant

_______________________________________________________________

Signature and Title of Authorized Official Date

_______________________________________________________________

Print Name of Authorized Official

If you have any questions regarding the application, or the application process, please call the Office of Enterprise Support Programs, Federal Real Property Assistance Program, at (301)443-2265.

Attachment A

Applicant Certification

1. The applicant will not discriminate on the basis of race, color, national origin, religion, sex, age, familial status, or handicap in the use of the property, and will maintain the records required to demonstrate compliance with the following Federal laws: section 606 of the Federal Property and Administrative Services Act of 1949; the Fair Housing Act (42 U.S.C. § 3601-19); Executive Order 11063 (Equal Opportunity in Housing), as applicable; Title VI of the Civil Rights Act of 1964 (42 U.S.C. § 2000d to d-4) (Nondiscrimination in Federally Assisted Programs); Title IX of the Education Amendments of 1972 (20 U.S.C. § 1681); the prohibitions against discrimination on the basis of age under the Age Discrimination Act of 1975 (42 U.S.C. § 6101-07) and implementing regulations; and the prohibitions against otherwise qualified individuals with handicaps under Section 504 of the Rehabilitation Act of 1973 (29 U.S.C. § 794); the Architectural Barriers Act Accessibility Standards (ABAAS) (36 CFR 1191, Appendices C and D); and all other implementing regulations for the above listed statutes.

2. The applicant agrees for itself, its successors and assigns, that it shall insure all conveyed improvements against loss, damage, or destruction. If any such loss, damage, or destruction shall occur during the period grantee holds title to said property subject to conditions subsequent 1 through 5, said insurance and all monies shall be held in trust by the grantee, its successors or assigns, and shall be promptly used by the grantee for the purpose of repairing such improvements and restoring the same to their former condition and use or for the purpose of replacing said improvements with equivalent or more suitable improvements or, if not so used, the grantee shall cause to be paid over to the Treasurer of the United States that part of the insurance proceeds that is attributable to the Government's reversionary interest in the property lost, damaged, or destroyed, determined on the basis of the fair market value of the facilities at the time of the loss, damage, or destruction.

3. The applicant covenants and agrees for itself, its successors and assigns, that in the event the grantor exercises its option to revert all right, title, and interest in the property to the grantor, or the grantee voluntarily returns title to the property, the grantee shall provide protection to and maintenance of the property until such time as the title reverts to and is accepted by the grantor. Such protection and maintenance shall, at a minimum, conform to the standards prescribed by the General Services Administration in its Customer Guidance for Real Property Disposal in effect as of the date of the deed, as referred to in the Federal Management Regulations (FMR) §102-75.965 (41 CFR 102-75.965). A copy of the applicable portions are attached (Attachment D) to the application.

____________________________________________________________________

Name of Applicant

____________________________________________________________________

Signature and Title of Authorized Official Date

____________________________________________________________________

Print Name of Authorized Official

Attachment B

Resolution to Acquire Property

Whereas, certain real property owned by the United States, located in the County of

______________________, State of ______________________, has been declared surplus and is subject to assignment for disposal for public health purposes by the Secretary of Health and Human Services under the provisions of Section 203(k)(1) of the Federal Property and Administrative Services Act of 1949, as amended, and regulations promulgated pursuant thereto, more particularly described as follows [Please insert property name and description below (full legal description is not required at this time)]:

Whereas, _____________________________________________________________________,

^{(Legal name of applicant)}

needs and can utilize said property for public health purposes in accordance with the requirements of said Act and the rules and regulations promulgated pursuant thereto, of which this Board is fully informed, including commitments regarding use and time within which such use shall commence.

Now, Therefore, Be It Resolved, that _______________________________________________

^{(Legal name of applicant)}

has legal authority, is willing, and is in a position financially and otherwise to assume immediate

care and maintenance of the property, and that ________________________________________,

^{(Name of Official(s) legally authorized)}

_______________________________, is/are hereby authorized, for and on behalf of the

^{(Title of Official(s))}

__________________________________________________________to do and perform any

^{(Legal name of applicant)}

and all acts and things which may be necessary to carry out the foregoing resolution, including the preparing, making, and filing of plans, applications, reports, and other documents; the execution, acceptance, delivery, and recordation of agreements, deeds and other instruments pertaining to the transfer of said property; and the payment of any and all sums necessary on account of the purchase price thereof, including fees or costs incurred in connection with the transfer of said property for surveys, title searches, appraisals, recordation of instruments, or escrow costs, together with any payments by virtue of nonuse or deferral of use of the property.

If the applicant is unable to place the property into use with the time limitation indicated below (or determines that a deferral of use should occur), it is understood that the

________________________________________________________ will pay to the Department

(Legal name of the applicant)

of Health and Human Services for each month of nonuse beginning twelve (12) months after the date of the deed, or thirty-six (36) months where construction or major renovation is contemplated, the sum of 1/360 of the then market value for each month of nonuse.

If the Department of Health and Human Services approves the application, the board will file a copy of the application and standard deed/lease with their permanent minutes.

__________________________________________________________________

Legal Title of Governing Body of Applicant

__________________________________________________________________

Address

__________________________________________________________________

City State Zip Code

I, ___________________________________, hereby certify that I am the

^{(Name of Certifying Officer)}

___________________________________, of the ____________________________________

(Title of Certifying Officer) (Title of Governing Body)

and that the foregoing resolution is a true and correct copy of the resolution adopted by the vote

of a majority of members of ____________________________ present at a meeting of said

^{(Title of Governing Board)}

Board on_____________ day ________________, 20____at which a quorum was present.

_________________________________­___

Signature of Certifying Officer

Note: The person named in the Resolution cannot sign as the Certifying Officer.

Attachment C

Environmental Questionnaire

Introduction

The Department of Health and Human Services (HHS) is required to include environmental information in its decision-making activities, including the consideration of applications for the use of excess and surplus real property for public health purposes under the Federal Property Assistance Program. It is therefore necessary for the applicant to submit environmental information to HHS. HHS uses this information to evaluate the potential environmental impacts of your proposed program of use, as described in your application.

The General Services Administration (GSA) and other agencies (when appropriate) have included environmental information in their management of the property, including the decision to make it available for this program. However, the information provided by GSA or other agencies does not include information about your program’s use of the property including various actions and/or activities which were unknown to the other agencies at the time of their disposal decisions.

This application is a request for HHS action (the transfer of Federal property). Therefore, HHS retains the responsibility to evaluate independently the adequacy and accuracy of the information submitted, and to make its own evaluation of the environmental issues which may arise.

HHS will use the requested information to determine if the requested action is a Categorical Exclusion (CatEx) in accordance with the National Environmental Policy Act (NEPA) and its implementing regulations. If the action is a CatEx, no further environmental review is required. However, if there is insufficient information to make a determination, additional information will be required. In some circumstances, such as the renovation of a Historic Property or major construction, HHS may approve an incomplete application, subject to the completion of an Environmental Assessment (EA) or an Environmental Impact Statement (EIS), if the application is otherwise complete. If the applicant does not cooperate or refuse to provide requested information for either an EA or an EIS, HHS will consider the application incomplete, and thus disapproved.

Instructions

Please give a detailed response for each question. If a question is not applicable, state as such along with any information that lead to that determination. Applicants must provide a basis for determination for each answer and attach all relevant documents used to answer the questions. Number and answer each question as presented, and include the applicant organization’s name and the property’s name and location (municipality, and State) on the top of each page.

There is no need to duplicate any efforts made elsewhere. If an EA or an EIS has been prepared on the proposed project for another local, state, or Federal agency which addresses all of the requested information, attach the EA or EIS in lieu of attaching a completed questionnaire.

Failure to provide the requested information will necessitate returning the application for completion.

Basis for Determination and Documentation

The basis for determination and any requisite documentation must be traceable and establish the factual data to support the response to each question. The information may include, but is not limited to:

• Printed Material: comprehensive land use plans, zoning maps, city master plans, environmental baseline surveys, an EA/EIS, other documented Federal determinations, etc.;

• Personal Contacts: communication with accepted authorities on the subject(s) along with supporting documentation, including the name, organization, the title of the person contacted and the date of the conversation; and

• Site Visit: initial inspection of the property, and surrounding area, in order to make preliminary determinations regarding environmental issues, along with supporting documentation including the date of the site visit, by whom, and observations; testing or sampling not required at this time.

Guidance

• The requested information will assist HHS in the environmental review of the proposed Federal action – transferring the property to the applicant organization. Detailed and clearly stated responses allow HHS to more efficiently and accurately assess the environmental impact, and are in the applicant organization’s best interest.

• Several questions ask to compare the proposed use to the prior use. If the property is currently a vacant structure, use the last occupied use of the structure as the point of comparison. If the structure has been vacant for an extended period of time, or is an undeveloped tract of land, use its current unoccupied state as the point of reference.

• The questions focus on the impact of the proposed use of property on the surrounding environment or the demands of the program on public resources. To better answer these questions, keep in mind the demographics of the area and the demographics of the clientele, including age, served by the proposed program. For example, if the surrounding area is industrial or undeveloped, a temporary shelter for homeless youth will have a different demographic than the surrounding area and most likely require different and/or additional public resources.

• Due diligence is expected. It is not necessary to consult an environmental professional, but applicants should research any unknowns and are encouraged to contact local and State officials for information, along with requesting any available information from the land-holding Federal agency, the General Services Administration (GSA), and the U.S. Department of Housing and Urban Development (HUD).

• Applicants may contact the disposal agency to arrange a site visit.

• Please be sure that any information obtained is current and relevant. If a document is lengthy or otherwise difficult to attach to the application, provide a citation for the document so that an outside reviewer can locate the specific reference, e.g., author, document title, publication date, and page number.

• Applicants should contact HHS if they encounter any difficulty or confusion in trying to find requested information. Applicants may reach a Realty Specialist at (301)443-2265 or at rpb@psc.hhs.gov.

Questions

Current Condition of Property

1. If there are any structures on the property:

   1. List the year in which they were built.

   2. If the structure is over fifty (50) years-old:

      1. Is the structure on the National Register of Historic Places?

      2. Contact the State Historic Preservation Officer (SHPO) to determine if the proposed use will adversely impact a historic property. Document and provide a copy of any response from the SHPO.

2. Describe any current contamination or adverse environmental condition of the requested property and the ground water below the property. This includes lead-based paint and asbestos in any current structures on the property. Applicants should also list any publicly known contamination on neighboring sites, including if there are any sites on the U.S. Environmental Protection Agency’s National Priorities List (NPL) within 1 mile of the property (available at http://www.epa.gov/superfund/sites/npl/npl.htm). An in-depth search is not required.

3. State any known institutional controls on the property due to environmental contamination (this may include use restrictions, covenants, deed notices, etc. imposed by a prior owner or local, State, or Federal agency).

4. Provide copies of any relevant land use plans (Federal, state, or local) for the requested property, and explain any known conflict(s) with any relevant land use plans.

Waste and Pollution

5. What kind/amount of waste will the proposed program create (e.g. municipal waste, construction debris, hazardous waste)?

   1. If there will be any hazardous waste produced/disposed of on the property, please detail which activities will produce the waste. Such activities include, but are not limited to, dry cleaning, air conditioning repair and service, motor pools, automobile repair, welding, services stations, gas stations, landscaping, agricultural and farming activities, print shops, hospitals, clinics, and medical facilities.

   2. Detail the disposal plans for any hazardous waste.

6. What pollution prevention measures, if any, does the applicant plan for the location, design, construction, or operation of the proposed use (including soil, sedimentation, or erosion controls, and source reduction/recycling)?

7. Does your State or local government require a storm water control plan for the proposed use of the property?

Surrounding Community

8. What is the scope of the use of the surrounding property (e.g. residential, commercial, or mixed-use), and is the proposed use uncharacteristic of the area?

9. Will there be any change in the community noise level, relevant to the time of day, due to the proposed use of the property?

10. Describe any direct or indirect effect on nearby parkland, other public lands, or areas of recognized or scenic value.

11. Will the proposed use of the property emit, or cause to be emitted, any air pollutants?

12. Will the proposed use of the property change the amount of carbon dioxide and other green house gases released as compared to the prior use of the property?

Public Resources

13. Will the proposed program require the construction/development of any new public facilities or services (e.g. schools, medical facilities, roads, sewage, or public transportation)?

14. Will the proposed use of the property require an increase in or the generation of more energy/electricity? (Contact the local utility or supplier and document the name and date of contact.)

15. Will the proposed use of the property require an increase in other non-electric utilities such as natural gas?

16. Will the proposed use of the property change the amount of solid waste generated on the property compared to the prior use?

17. Will the proposed use of the property increase the amount of wastewater in need of treatment from the property compared to the prior use?

Federal Law

18. Safe Drinking Water:

    1. Is the property in proximity to an EPA designated sole source aquifer?

    2. Will the proposed use of the property change the amount of drinking water needed as compared to the prior use?

19. Floodplains:

    1. Is the property located in a flood plain?

    2. Will the proposed use of the property encourage development in a floodplain?

20. Wetlands and Navigable Waters (lakes, rivers, streams, etc.; including any ditch, culvert, or other source of water that has a hydrologic connection to a larger body of water):

    1. Are there any wetlands or water resources on or near the property?

    2. Does the proposed use of the property require construction in wetlands?

    3. If construction is required, will there be any dredging or filling of a wetland or water resource?

21. Costal Zone Management:

    1. Will the proposed use of the property directly affect a designated Coastal Zone? (Coastal Zones are not necessarily the area immediately next to the coast; some zones encompass the entire State, such as Florida, or major watersheds such as the Chesapeake Bay watershed.)

    2. If so, provide the State Coastal Zone Management Plan and highlight any potential conflicts? (Each State adjacent to a coast, including those located in the Great Lakes region, should have a State office to manage its coastal zone development and use.)

22. Wild and Scenic Rivers:

    1. Is the property located near a wild, scenic, or recreational river area?

    2. If so, will the proposed use create conditions inconsistent with the character of the river?

23. Farmland Protection:

    1. Will the proposed use of the property convert any agricultural lands to non-agricultural uses?

24. Wilderness:

    1. Is the property located near a designated Wilderness Area or other public land with a similar designation?

    2. If so, will the proposed use of the property affect, directly or indirectly, a Wilderness Area?

25. Endangered Species:

    1. Does the property have, or is it located near, any critical habitat of an endangered or threatened species?

    2. Will the proposed use of the property affect, directly or indirectly, any Federal or State listed endangered or threatened species?

Due Diligence

26. Demonstrate that the applicant has performed due diligence to ensure that the proposed use of the property will not result in a known violation of applicable (Federal, State, or local) laws or regulations that protect the environment or public health and safety. If the proposed use will result in a known violation, explain fully.

27. Describe, within reason, any known controversy over the environmental effects of the proposed use for the property.

Certification

28. Either complete a copy of the below certification or complete and remove this page from the application.

I, ______________________________________, certify that the information in the

(Name of Authorized Official)

Environmental Questionnaire is true, correct and accurate to the best of my knowledge.

I understand that HHS may require more environmental information prior to either the approval/disapproval of the application or transfer of the requested property. Such information may include, but is not limited to, Environmental Assessments or Environmental Impact Statements.

_______________________________________________________________

Name of Applicant

_______________________________________________________________

Signature and Title of Authorized Official Date

_______________________________________________________________

Print Name of Authorized Official

Attachment D

Protection and maintenance Standards

The following is an excerpt from the GSA’s Customer Guide to Real Property Disposal, as referred to in the Federal Management Regulations (FMR) §102-75.965 (41 CFR 102-75.965):

Protection Standards

For all protected properties--

• If a property is within the range of municipal or other public protection services but is outside the geographic boundaries of the service provider, then advance arrangements should be made with the local authorities to provide police and fire protection.

• If a property or facility has large areas that need protection, then use automobiles to patrol the area.

• If a property is fenced, only keep open a minimum number of gates.

Fire protection or security personnel are not needed at--

• Facilities that have no buildings, structures or related personal property.

• Facilities where the value of the improvements and/or related personal property (or realizable recovery of their value) is less than the cost to protect and maintain the property for one year.

• Facilities with little value, which can be locked or boarded up and are located within public police and fire department service areas.

• Facilities where major buildings do not contain large quantities of easily removable personal property and also are equipped with automatic sprinklers supervised by a monitoring service.

• Facilities where agreements can be made with a lessee of a portion of the property to protect the remaining portion(s) at no cost or nominal cost.

Properties that need a resident custodian (guard) are--

• Facilities containing little removable personal property but have many buildings that will be sold for off-site use when

- the buildings have low realizable value

- the buildings are spaced far enough apart that loss of more than a few buildings in a single fire is improbable

- the buildings are located near water for firefighting purposes and the local public fire and police protection services will respond promptly.

• Small inactive industrial and commercial facilities that need to remain open for inspection and public fire and police protection can be secured by telephone.

• Facilities whose highest and best use is salvage.

• Facilities with only salvage value but are potentially dangerous and attractive to children or curiosity seekers and posting signs is not sufficient to protect the public or the property.

Properties needing continuous guard service are--

• Fenced facilities with high market value require one guard on duty at all times (5 guards in total are required).

• These properties are permitted one open gate which can be locked during patrols.

• All buildings can be locked.

• Local fire and police protection can be secured by telephone.

Properties needing a high degree of protection

At a minimum, two firefighter-guards will be on duty at all times for the classes of facilities listed below. Consider all relevant and pertinent factors when deciding on the number and assignment of the guards.

• Facilities with a high market value that require an on-site fire-fighting force adequate to subdue fires until outside help arrives.

• Facilities with a high market value without access to outside assistance require an on-site fire-fighting force adequate to extinguish fires.

• Facilities with a high market value with large areas to patrol.

• Facilities with a high market value with no fencing and containing large quantities of personal property susceptible to pilferage.

• Facilities with a high market value needing several gates open for operating purposes.

Firefighter-Guards

Firefighters and guards provide fire protection and security for excess and surplus real property requiring both forms of protection. Combine the duties of each to the maximum extent possible. In the interest of cost savings, they can also be used for various miscellaneous services such as grass/weed removal, servicing fire extinguishers, and other activities related to the general protection of the property.

Operating Requirements of Protection Units

Firefighter-guards or guards should periodically patrol facilities requiring protection. The frequency of the patrols will be determined by the location and size of the facility, type of structures and physical barriers, and the amount and type of activity at the facility. In some instances, a centralized monitoring service provider will suffice.

Watchman’s Clock

To ensure adequate coverage of the entire property by firefighter-guards or guards, an approved watchman’s clock should be provided, with key stations strategically located to enable guards to cover the entire property.

Protection Alarm Equipment

Automatic fire detection devices and related equipment and services can substantially reduce protection costs. However, using these devices are primarily for obtaining fire and police protection in an emergency. Such devices can supplement or in some cases, eliminate the need for guard patrols.

Sentry Dogs

Some high market value facilities that cover a large area and/or are in remote locations, invite intrusion by curiosity seekers, hunters, vagrants, etc. These facilities require special protection measures. Using sentry dogs is a cost effective alternative to additional security personnel. Get advice on the use, care, and training from the nearest police department using sentry dogs. Also, when sentry dogs are used to protect government property, post a sign with view unobstructed that says "Warning—This Government Property Patrolled by Sentry Dogs."

Maintenance Standards

The following standards or criteria should be used as a guide for the upkeep of excess and surplus real property:

Temporary Buildings and Structures

Vacant temporary structures should not be maintained except in unusual circumstances. Temporary buildings housing personal property that cannot be readily removed to permanent structures should be maintained only to the extent necessary to protect the personal property.

Permanent Buildings and Structures

(a) Don’t paint the interior. Only spot paint exterior wood or metal surfaces to prevent serious deterioration.

(b) Limit carpentry and glazing to only that which is necessary to close openings to prevent weather damage and pilferage, repair damage to floors, roofs, and side-walls to prevent further damage, shoring and bracing to prevent structural damage, and other similar operations.

(c) Patch damage to roofing and sheet metal as necessary.

(d) Perform masonry repairs, such as brick, tile, and concrete work only to prevent leakage or disintegration or to protect against imminent structural damage.

(e) Don’t heat buildings for maintenance purposes except in unusual circumstances.

Mechanical and Electrical Installations

These include plumbing, heating, ventilating, air conditioning, sprinkler systems, fire alarm systems, electrical equipment, elevators, and other similar systems.

For inactive facilities:

• Maintain mechanical and electrical systems only when necessary to stop or prevent serious deterioration.

• Employ personnel for this work temporarily, at periodic intervals when an inspection indicates that this work is necessary.

• De-energize electrical systems, drain water from all fixtures, turn off heat, and secure the building against unauthorized entry.

• Drain sprinkler systems during freezing weather and reactivate when there is no danger of freezing.

For active facilities:

• Keep equipment in reasonable operating condition.

• Operate equipment to service private tenants or procure utility services to distribute to private tenants only to the extent necessary to comply with a lease or permit, or in cases where tenants can’t get these services directly from utility companies or other sources.

• Inspect (periodically) facilities that have elevators and/or high-pressure boilers and related equipment. Inspections should be made by qualified, licensed inspectors to protect against injury or death to personnel and damage to property.

• Use individual heaters, when practical, instead of operating heating plants.

Grounds, Roads, Railroads, and Fencing

• Limit grounds maintenance to the removal of vegetation in order to avoid fire hazards and to control poisonous or noxious plant growth in accordance with State and local laws and regulations.

• Plow fire lanes where needed.

• Remove snow from roads and other areas to the extent necessary for access for maintenance, fire protection, and other similar activities.

• Sell hay crops (wherever practicable) to the highest bidder (s) with the purchaser performing all labor in connection with cutting and removal.

• Use agricultural and/or grazing leases to reduce costs of grounds maintenance, where practical.

• Maintain the portion of road network necessary for fire trucks and other minimum traffic. These roads should be maintained to the extent necessary to allow safe passage at a reasonable speed.

• Maintain railroads to the extent necessary for protection and maintenance operations or as required in lease or permit provisions.

• Clear ditches and drainage facilities to allow surface water run-off.

• Fencing and other physical barriers should be sufficient to protect against unauthorized entry.

Utilities

In cases where utilities are purchased by contract, review the utility contracts to see if you can save money by revising them.

For inactive properties:

• Maintain water systems, sewage disposal systems, electrical distribution systems, etc., to the extent necessary to provide minimum service.

• De-energize electrical systems and turn off the water in buildings or areas that don’t require these services.

• Don’t maintain utilities not in use or that service dismantled or abandoned buildings/structures.

For active properties:

• Operation rates for water supply, electrical power, and sewage disposal facilities should be far below normal capacities.

• Use engineering studies to determine structural and operating changes necessary for maximum economy.

• Turn off, rather than repair, leaky water lines unless they are necessary for fire protection or other purposes.

Properties Disposed of as Salvage

Do not spend money to maintain property whose highest and best use is salvage.

Repairs

Limit repairs to additions or changes necessary for preservation and maintenance of the property to--

• Deter or prevent excessive, rapid, or dangerous deterioration or obsolescence.

• Restore property damaged by storm, flood, fire, accident, or earthquake when restoration is required.

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