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HomeMy WebLinkAboutPart 1 - Offsite Indoor Air, Sub-Slab Vapor and Outdoor Air (Part 1 - Offsite Indoor Air, Sub-Slab Vapor and Outdoor Air Field Investigative Reportx9E5D1) 14710 NE 87"'Street,Suite 100 Redmond,Washington 98052 �r wLEIN ELDE R fl 425.636.790 /1 fl 425.636.7901 Bright People.Right S014U60 , klelnfelder.com Prepared for: The City of Bozeman Montana CVS Pharmacy LLC c/o Jenifer Reece c/o Susan Phillips Moore, O'Connell & Refling Mintz, Levin, Cohn, Ferris, Glovsky and Suite 10, Life of Montana Building Popeo, P.C. P.O. Box 1288 One Financial Center Bozeman, Montana 69771-1288 Boston MA 02111 OFFSITE INDOOR AIR, SUB-SLAB VAPOR, AND OUTDOOR AIR FIELD INVESTIGATION REPORT BOZEMAN SOLVENT SITE BOZEMAN, MONTANA Prepared by: �. woo Michael G. Ellerd Scott D. Dwyer, PhD, DABT Principal Scientist Risk Analysis & Toxicology Practice Leader ATC Associates Inc. Kleinfelder ATC ASSOCIATES, INC. KLEINFELDER WEST, INC. PO Box 116 14710 NE 871h Street, Suite 100 Bozeman MT 59771 Redmond WA 98052 Office: 406-794-5711 Office: 425-636-7900 Fax: 406-259-1099 Fax: 425-636-7901 October 26, 2010 Kleinfelder Project Number 73766 TABLE OF CONTENTS 1.0 INTRODUCTION.................................................................................................. 1 1.1 BACKGROUND INFORMATION AND SITE DESCRIPTION .................... 1 2.0 FIELD INVESTIGATION PLAN............................................................................5 2.1 SELECTION OF SAMPLING LOCATIONS ...............................................6 2.2 PRE-SAMPLING STRUCTURE AND CHEMICAL STORAGE INSPECTION............................................................................................. 8 2.3 UTILITY LOCATING.................................................................................. 8 2.4 INDOOR AIR SAMPLE COLLECTION ......................................................9 2.5 OUTDOOR AIR SAMPLE COLLECTION ................................................ 10 2.6 INSTALLATION, DESIGN, AND SAMPLE COLLECTION FROM INTERIOR SUB-SLAB VAPOR PROBES................................................ 11 2.7 SAMPLE ANALYSIS AND DATA VALIDATION ...................................... 13 2.8 HANDLING AND SHIPPING OF AIR SAMPLES..................................... 15 2.9 COLLECTION OF WEATHER DATA....................................................... 15 2.10 ACCESS ARRANGEMENTS................................................................... 15 2.11 SAMPLE LABELING AND IDENTIFICATION.......................................... 15 3.0 RESULTS AND DISCUSSION............................................................................17 4.0 REFERENCES...................................................................................................20 TABLE Table 1 — Summary of PCE Concentrations (Ng/m3) in Sub-slab Soil Vapor, Crawlspace, and Indoor Air Samples, Residential Study Area FIGURES Figure 1 — Study Area Figure 2 — Source Areas at the Former Buttrey's Shopping Center Figure 3—Soil Vapor Sampling Locations, June 2009 Figure 4— Soil Vapor Results by Location, June 2009 Figure 5— Residential Study Area Figure 6 — Structures Selected for Indoor Air Testing Figure 7— Map of Residential and Commercial Structures Tested in the Residential Study Area (RSA) Figure 8 — Schematic Diagrams of Residential and Commercial Structures APPENDICES Appendix A— Pre-sampling Inspection and Chemical Inventory Forms Appendix B — Laboratory Analytical Data Validation Summary Appendix C — Meteorological Data Appendix D — Field Data Sheets Appendix E—Vapor Intrusion Decision-making Framework Appendix F —Analytical Laboratory Reports 73766/SEA10R091 Page i of i October 26, 2010 KLEINFELDER 14710 NE 81" Street,Suite A100,Redmond,WA 98052 p i 425.636.7900 f i 425.636.7901 1.0 INTRODUCTION On behalf of the City of Bozeman (City) and Montana CVS Pharmacy LLC (CVS), ATC Associates Inc (ATC) and Kieinfelder performed a sub-slab vapor and indoor air investigation, as part of the Bozeman Solvent Site vapor intrusion investigation, in the area located north of the former Buttrey's Shopping Center (BSC) site in Bozeman, Montana (Figure 1). A soil vapor survey completed in June 2009 revealed that soil vapor concentrations of tetrachloroethene (also known as perchloroethene or PCE) exceeded a target screening level of 4.1 micrograms per cubic meter (Ng/m3), established by the Montana Department of Environmental Quality (MDEQ 2009a), in 26 of 27 samples collected in an area north of the former BSC (Kleinfelder 2009a). The MDEQ target screening level is based on the Environmental Protection Agency (EPA) residential indoor air Regional Screening Level (RSL) of 0.41 fag/m3 adjusted by an attenuation factor of 0.1. Therefore, the objective of the study described in this report was to collect additional information necessary to assess the potential for migration of vapors from groundwater affected by releases from a dry cleaner formerly located at the BSC into homes or other structures located north of the BSC. For the purposes of this investigation a subset of structures within an area identified as the Residential Study Area was sampled. 1.1 BACKGROUND INFORMATION AND SITE DESCRIPTION In 1989, chlorinated solvents were discovered in groundwater north of the BSC, and the source was subsequently identified as the former dry cleaning operation at the BSC. PCE was discharged into a local sewer line and subsequently entered the subsurface through failures in the sewer lii?e and through a septic tank and associated leach system (septic system). The septic system, including septic tank sludge, was removed and impacted soil was excavated and transported to a hazardous waste facility for disposal. Following discovery of the release, numerous investigations were performed at tee site and five separate zones of PCE impacts were identified (NE&W 1995, 1999). Zones 2 and 3 are considered residual source zones for PCE dissolution into groundwater. These two zones are located at the northeast corner of the BSC building occupied by CVS Pharmacy: Zone 2 is located adjacent to, and on the north side of, the CVS Pharmacy where the former sewer line failed; and Zone 3 is located on the east side of the CVS Pharmacy at the site of the former septic system (Figure 2). 73766/SEA1 OR091 'age 1 of 23 October 26, 2010 KLEINFELDER 14710 NE 87h Street,Suite A100,Redmond,WA 98052 p l 425.636.7900 f 1425.636.7901 Following discovery of the release points, the inlet to the septic system was sealed in 1990 and the system was removed in 1992. A new sewer line was installed and entered service in 1994. Soil vapor extraction (SVE) systems were installed in Zones 2 and 3 as a means of source removal. SVE systems operated intermittently from approximately March 1993 to September 1998 (NE&W 1999). After obtaining approval from MDEQ, a bioremediation pilot test was implemented at the source area in 2008 and continued into 2009 (ATC 2009a). The site has been monitored on a regular basis over the history of the project, with the most recent event conducted in June 2009 (ATC 2009b). In 2007, 'MDEQ required a soil vapor, indoor air, and outdoor air investigation that focused on the Hastings and CVS retail commercial spaces. This investigation was performed in September 2007 (Kleinfelder 2008). PCE and TCE concentrations measured during the 2007 investigation did not exceed EPA industrial indoor air RSLs. In March 2009, a similar follow-up investigation was performed to collect samples under a "worse case" scenario during the heating season when stack effects are expected to be the greatest and to extend the investigation into the south leg of the shopping center building in a retail commercial space formerly occupied by Corral West Ranchwear (Kleinfelder 2009b). The results of the March 2009 investigation indicated that only PCE present in indoor air samples from the Hastings space exceeded the EPA industrial indoor air RSL of 2.1 pg/m3. All other chemicals in Hastings, and all chemicals in CVS and Corral West, were either not detected, were detected but at concentrations less than the corresponding RSL, or were present in indoor air but not likely due to migration of soil vapor at the BSC to indoor air because the indoor air concentrations were greater than the soil vapor concentrations. Previous investigations at the BSC have revealed the presence of PCE and other chlorinated organic compounds in groundwater, soil vapor, indoor air, and outdoor air (Maxim 2005, 2006; RTI 2006; Kleinfelder 2008, 2009b). The concentration of PCE and other volatile organic compounds (VOCs) has been monitored in groundwater within the boundaries of the former BSC and in groundwater migrating from the BSC to the north (ATC 2009b). Recently, the MDEQ used the Johnson and Ettinger model (EQM 2004) for vapor intrusion into buildings to predict possible indoor air concentrations that might occur in homes or other structures based on the concentrations of PCE measured in two off-site monitoring wells: M-28 and M-8 (MDEQ 2009b). Modeled indoor air 73766/SEA10R091 Page 2 of 23 October 26, 2010 KLEINFELDER 14710 NE 87°i Street,Suite A100,Redmond,WA 98052 p1425.636.7900 f1425.636.7901 concentrations of PCE ranged from 2 pg/m3 to 14.2 pg/m3. For comparison, the EPA Regional Screening Level for residential indoor air is 0.41 pg/m3 (EPA 2008). On the basis of the MDEQ's modeling, MDEQ required the preparation of an off-site vapor intrusion investigation work plan in a letter from Cindy Brooks, MDEQ, to the City and CVS, March 11, 2009 (MDEQ 2009a). Kleinfelder and ATC prepared the off-site soil vapor investigation work plan (Kleinfelder 2009c) and MDEQ approved that plan, with minor revisions, on June 5, 2009 (MDEQ 2009c). The of-site soil vapor survey was completed in June 2009 (Kleinfelder 2009a). A groundwater monitoring event was performed concurrently and provided data for comparison to the soil vapor survey. The survey included the collection of soil vapor samples from one location on the former BSC property and 14 locations from public rights-of-way in the residential area north of the former BSC (Figure 3). At all locations except one, where the groundwater elevation was too shallow for the collection of a deeper sample, soil vapor samples were collected from two depths: five feet below ground surface (bgs) and within two feet of the capillary fringe zone above the water table. The deeper of the two samples was collected from approximately eight and 12 feet bgs depending on the location. All soil vapor samples were analyzed by U.S. EPA Method TO-15. The results of the soil vapor sample analysis indicate that PCE, the primary chemical of concern (COC), was present at concentrations that exceeded the MDEQ target screening level of 4.1 pg/m3 in all of the deep soil vapor samples and all but one of the shallow (five feet bgs) samples (Figure 4). As previously menticned, the MDEQ target screening level was based on the EPA residential indoor air RSL of 0.41 pg/m3 adjusted by.an attenuation factor of 0.1. The MDEQ stated in a March 11, 2009 to the City and CVS that sub-s!ab soil vapor and indoor air sampling would be required if soil vapor concentrations from any of the soil vapor sample points exceeded the target screening level of 0.41 pg/m3. In a September 4, 2009 letter to the City and CVS from Cindy Brooks, MDEQ (MDEQ 2009d), DEQ required that indoor air sample results be compared to the April 2009 EPA RSLs. 73766/SEA10R091 Page 3 of 23 October 26, 2010 KLEINFELDER 14710 NE 87'h Street,Suite A100,Redmond,WA 98052 p 1425.636.7900 f 1425.636.7901 This report documents two rounds of indoor air and sub-slab vapor sample collection and analysis from a subset of structures within an area identified as the Residential Study Area (Figure 5). Based on the results of the investigation described herein and the site-specific cleanup levels (SSCL) for residential and commercial indoor air, MDEQ determined it would not require further action to address subsurface PCE vapors in the Residential Study Area at this time. 73766/SEA10R091 Page 4 of 23 October 26, 2010 KLEINFELDER 14710 ONE 87"'Street,Suite A100,Redmond,WA 98052 p l 425.636.7900 f l 425.636.7901 2.0 FIELD INVESTIGATION PLAN In response to the MDEQ's concern over the possible partitioning of PCE from groundwater and migration through the unsaturated zone as PCE vapor, the City and CVS proposed during a March 5, 2009 conference call with the MDEQ that a phased approach be implemented to evaluate this potential. Initially, three phases of investigation were proposed: a soil vapor survey limited to city rights-of-way, a second phase of soil vapor sampling adjacent to structure foundations in the Residential Study Area, and a third phase that included sub-slab vapor and indoor air sampling from within structures in the Residential Study Area. Based on the results of the first phase of investigation (the soil vapor survey in City rights-of-way), the initial approach was revised and the next phase of investigation, as described in this report, was limited to the collection and analysis of sub-slab vapor and indoor air samples from structures in, and outdoor air samples from the area around, the Residential Study Area. The investigation documented in this report was designed to support the following objectives: • Identify the boundaries of the area wherein PCE vapors originating from releases on the former BSC could migrate into off site structures and result in indoor air concentrations of PCE that exceed the residential indoor air RSL of 0.41 pg/m3 or the industrial indoor air RSL of 2.1 pg/m3. • Assess whether the vapor intrusion pathway is complete in off-site structures and if indoor air concentrations of volatile organic compounds in sampled structures exceed compound-specific RSLs. Three sets of air and sub-slab vapor samples were collected to achieve the objectives identified above: 1. Indoor air samples from structures in the Residential Study Area; 2. Sub�slab vapor samples from structures in the Residential Study Area; and 3. Outdoor air samples in the Residential Study Area. This field investigation work plan (Kleinfelder 2009d) was prepared in general accordance with MDEQ's September 4, 2009 letter (MDEQ 2009d), comments received from MDEQ r, a letter dated Octcbe; 14, 2009 (MDEQ 2009e), and generally adhered to the following guFdance documents: 73766/SEA10R091 Page 5 of 23 October 26, 2010 KLEINFELDER 14710 NE 87th Street,Suite A100,Redmond,WA 98052 p J 425.636.7900 f[425.636.7901 DTSC (Department of Toxic Substances Control). 2004. Interim Final Guidance for the Evaluation and Mitigation of Subsurface Vapor Intrusion to Indoor Air. December 15. Revised February 7, 2005. ITRC. 2007. Vapor Intrusion Pathway: A Practical Guideline. Interstate Technical and Regulatory Council. Washington DC. January. EPA. 2002. OSWER Draft Guidance for Evaluating the Vapor Intrusion to Indoor Air Pathway from Groundwater and Soils (Subsurface Vapor Intrusion Guidance). EPA 530-D-02-004. Office of Solid Waste and Emergency Response, Washington DC. November. Cal/EPA (California Environmental Protection Agency). 2003. Advisory — Active Soil Gas Investigation. Jointly issued by the Regional Water Quality Control Board, Los Angeles Region and the Department of Toxic Substances Control. January 28, 2003. EPA. 1995. Environmental Response Team, Standard Operating Procedures #1704: Summa Canister Sampling. July 27. EPA. 1994. Environmental Response Team, Standard Operating Procedures #2008: General Air Sampling Guidelines. November 16. 2.1 SELECTION OF SAMPLING LOCATIONS The selection of sampling locations was made to address the two stated objectives of the work plan. Therefore, indoor air, sub-slab vapor, and outdoor air samples were collected from residential properties and one business property north of the former BSC in the Residential Study Area (Figure 5). Final selection of all sample locations was made jointly by ATC, Kleinfelder, and the MDEQ. Indoor air and sub-slab vapor samples were collected from a sub-set of structures within the Residential Study Area bounded by West Beall Street, North 15th Avenue, Durston Road, and North 18th Avenue (Figure 5). There are approximately 106 structures within the Residential Study Area. MDEQ required that at least 20% of these structures be sampled. Therefore, the City and CVS collected samples from 21 structures within the Residential Study Area. This sample set was designed to provide sufficient data to identify whether vapor intrusion was occurring in this area, whether the vapor intrusion could be the result of releases from the former BSC to groundwater, and whether additional sampling could be needed. The City and CVS prepared an inventory of the structures within the Residential Study Area. The inventory included the type of 73766/SEA10R091 Page 6 of 23 October 26, 2010 KLEINFELDER 14710 ONE 874'Street,Suite A100,Redmond,WA 98052 p l 425.636.7900 f l 425.636.7901 structure (e.g., business, single family, multi-family), construction type (e.g., ranch, multi-story, basement, split-level, daylight basement, etc), and the year each structure was built. The City and CVS submitted the inventory to the MDEQ on October 30, 2009. Based on this inventory and a site visit to verify structural designs, the City, CVS, and IVIDEQ identified 21 proposed target structures (and 29 alternate structures) to be sampled based on the different structure types identified within the Residential Study Area. Selection of target structures also considered the location of the structure to gjInw for a representative distribution of sample locations within the Residential Study Area. The proposed sample locations were submitted to the MDEQ with the inventory described above on November 30, 2010. The final sample locations were representative of the different structure types in the Residential Study Area and provided adequate spatial distribution of the different structure types within the Residential Study Area. After approval of the proposed target structures, and after final sample locations (structures) were approved by MDEQ, the City and CVS contacted properly owners and made the necessary access arrangements. At least one indoor air sample was collected from each floor in each of the 21 target structures, including the basement. One sub-slab vapor sample also was collected from a location as close to the center of the foundation slab as possible. During the first round of sampling performed in January 2010, two outdoor air samples were collected from the Residential Study Area on each day that indoor air and sub-slab sampling was conducted. The number of outdoor air samples collected was reduced to one per day during the second round of sampling in March 2010 based on the low level of variability in the upwind and downwind samples collected during the first round of sampling. The location of the outdoor samples was based on the prevailing wind direction at the time of sampling (generally westerly). The outdoor air samples collected from the upwind side of the residential area were collected in Summa canisters placed on a street fight standard on North 19th Avenue. The outdoor air samples collected from the downwind side of the residential area were collected in Summa canisters piaced on a street light standard on North 15th Avenue. 73766/SEA10R091 Page 7 of 23 October 26, 2010 KLEINFELDER 14710 NE 874'Street,Suite A100,Redmond,WA 98052 F 1425.636.7900 f l 425.636.7901 2.2 PRE-SAMPLING STRUCTURE AND CHEMICAL STORAGE INSPECTION Before sampling indoor air or sub-slab vapor, an inspection of the selected homes and businesses was performed by ATC personnel to identify conditions that might affect the quality and reliability of each indoor air or soil vapor sample.' The pre-sampling inspection addressed the following building and use characteristics: • Structure type and floor plan (the basic structure type was obtained prior to the pre-sampling inspection, but was noted here as well); • Building construction materials; • Physical condition of building; • Floor drains and sumps; • Windows and doors (number, type, and -duration and frequency of window and door openings); • Foundation type; • Water supply and sewage management; • HVAC system; • Potential indoor sources of air pollution, e.g., chemicals used in the normal course of business or home ownership; and a • Chemical product inventory. A pre-sampling inspection form/questionnaire and chemical inventory form were completed for each structure sampled in the off-site indoor air and sub-slab soil vapor investigation (Appendix A). The questionnaire was part of the work plan approved by MDEQ for the investigation described in this report (Kleinfelder 2009d). 2.3 UTILITY LOCATING Underground utilities were identified and located in each target structure before any intrusive work, including interior sub-slab locations, was undertaken. Underground utilities on private property were located by Magic Valley Private Locates of Burley, Idaho. All soil vapor probes were installed, and all indoor air, outdoor air, and sub-slab vapor collection was performed, by Kleinfelder and ATC field scientists experienced with the methods described in this and previous scopes of work (Kleinfelder 2007, 2009c). 73766/SEA10R091 Page 8 of 23 October 26, 2010 KLEINFELDER 14710 NE 87h Street,Suite A100,Redmond,WA 98052 p l 425.636.7900 f l 425.636.7901 2.4 INDOOR AIR SAMPLE COLLECTION In the first round of sampling performed in .January 2010, indoor air samples were collected from 21 structures within the Residential Study Area; one indoor air sample was collected from each floor, including the basement. Thus, up to three indoor air samples were collected from each structure corresponding to the basement or ground floor (first floor), second floor, and third floor. Indoor air samples were collected after the sub-slab vapor samples had been collected and the sub-slab vapor probe had been sealed in a given structure. Six-liter SummaTM canisters and dedicated flow controllers were field-checked for vacuum pressure with a laboratory-supplied pressure gauge, prior to use. All canisters used to collect air samples had initial pressures of at feast -23 inches of mercury (inHg). Summa"m canisters were shipped from the laboratory with an initial pressure of -29.9 inHg. The difference in elevation between the laboratory and the Bozeman site is approximately 4,500 to 4,700 feet so a correction factor of 0.8446 (personal communication, Kelly Buettner, Air Toxics, Ltd.) was applied to the canister pressure. Assuming no loss of pressure, the canister pressure on arrival at the Bozeman site should have been about -25.3 inHg after correction for elevation. The canisters were checked with field gauges before use and because the field gauges may be somewhat imprecise, a decision based on best professional judgment was made to allow a variance of up to ±2 inHg before a canister was rejected. Therefore, canisters with an initial pressure not less than -23 inHg were considered acceptable for sample collection. Each SummaTM canister for indoor air sample collection was fitted with a flow restrictor calibrated for sample collection at a rate of approximately four milliners per minute to achieve a 24-hour sample collection time. All SummaTM" canisters used to collect indoor air were Selective Ion Monitoring (SIM)-certified clean by the laboratory. SIM-certified indicates that the SummaTM canisters were certified clean by the vendor for EPA Method TO-15 analytes to a detection limit equivalent to the TO-15 SIM analysis. To collect indoor air samples, the SummaTM" canisters were staged three to five feet above floor level to collect indoor air samples that represented the breathing zone. Indoor air samples were collected by opening the SummaTM" canister valve for approximately 24-hours. Following sample collection, the SummaTM" canister was closed and sealed with a laboratory-supplied brass cap. Beginning and ending times and canister pressures were recorded on chain-of-custody forms and sample labels. 73766/SEA10R091 Page 9 of 23 October 26, 2010 KLEINFELDER 14710 NE 87"'Street,Suite A100,Redmond,WA 98052 p 1425.636.7900 f 1425.636.7901 Duplicate indoor samples were collected for the validation of data quality at a rate of approximately one duplicate sample for each 10 indoor samples. The duplicate samples were collected using duplicate sampling-T's created from dedicated polyethylene Teflon TM-linedtubing that allows the collection of two SummaTM canister samples from the same sample point. 2.5 OUTDOOR AIR SAMPLE COLLECTION In the first round of sampling, outdoor air samples were simultaneously collected, one from the upwind side on North 19th Avenue and one from the downwind side on North 15th Avenue in the Residential Study Area, during each day that indoor air and sub-slab samples area collected. Weather data also were collected each day of indoor and outdoor air sample collection to assess meteorological conditions that could affect sample collection and analytical results. Six-liter SummaTM canisters were field-checked for vacuum pressure with a laboratory- supplied pressure gauge, prior to use. All canisters had initial pressures at least -23 inHg or were not used. Each SummaTM canister used for outdoor air sample collection was fitted with a flow restrictor calibrated for sample collection at a rate of approximately four milliliters per minute to achieve a 24-hour sample collection time. All SummaTM canisters used to collect outdoor air were SIM-certified clean by the laboratory. Outdoor air samples were collected by attaching the SummaTM canister to a street light standard approximately 12 feet above the ground. The placement of the outdoor air samples at 12 feet above the ground was a deviation from the work plan which specified samples would be placed 5 feet above the ground. This deviation was necessary to prevent vandalism or theft of the canisters. Outdoor air samples were collected by opening the SummaTM canister valve for approximately 24 hours to allow the flow of outdoor air into the canister at a rate fixed by the flow controller. Following sample collection, the SummaTM canister was closed and sealed with a laboratory-supplied brass cap. Beginning and ending times and canister pressures were recorded on chain- of-custody forms and sample labels. 73766/SEA10R091 Page 10 of 23 October 26, 2010 KLEINFELDER 14710 NE 87"'Street,Suite A100,Redmond,WA 98052 p l 425.636.7900 f l 425.636.7901 2.6 INSTALLATION, DESIGN, AND SAMPLE COLLECTION FROM INTERIOR SUB-SLAB VAPOR PROBES The methods for installation of sub-slab vapor probes and sample collection described below are reproduced from the California Department of Toxic Substances Control (DTSC 2004): 1) Small-diameter holes (1.0 to 1.25 inches in diameter) were drilled through the concrete of the foundation slab. A BoschTm Roto-Hammer and a one-inch diameter drill bit were used to drill the holes. Prior to drilling, Magic Valley Locates of Burley, Idaho identified and clearly marked the locations of all sub-slab utilities. Sub-slab holes were advanced 6 to 12 inches into the sub-slab material. Each sampling probe location was prepared as described below: • Brass vapor probes were purchased from Pine Environmental (Part number 21013 • 6" Soil Vapor Impla�int with SS SWG lock fitting). The barbed top end of each probe was fitted with a length of flexible Teflon TM tubing (3/16-inch inner diameter; 1/4-inch outer-diameter) for attachment to a SummaTm canister. The brass vapor probe and tubing assembly were lowered into the boring until the base of the probe as approximately one-inch above the bottom of the boring. • No. 2 sand was used to fill the annular space around the brass vapor probe up to approximately one inch above the probe. • A Bentonite slurry was used to fill the borehole annular space above the sand pack to just below the surface of the concrete foundation. • The top of the boring was completed with quick-setting contaminant-free Portland cement. • Probes were not sampled for at least 30 minutes to allow for equilibration and for the cement to set. After completion of each floor slab bore hole, the drill bit and other re-useable equipment were decontaminated, to prevent cross contamination, using a three-stage wash and rinse procedure: • Wash with a non-phosphate detergent; • Tap water rinse; and • Distilled water rinse. 73766/SEA10R091 Page 11 of 23 October 26, 2010 KLEINFELDER 14710 NE 87"Street,Suite A100,Redmond,WA 98052 p 6 425.636.7900 f J 425.636.7901 Following the three-stage wash and rinse procedure, equipment was considered ready for re-use on the project site. The collection of sub-slab vapor samples generally followed the procedures in Cal-EPA (2003). Sub-slab vapor probes as follows: 1. The vapor sample points and associated tubing were purged to remove air in the sampling train that would otherwise dilute vapor samples. The appropriate purge volume was estimated according to the method of Cal/EPA (2003); 2. Dead space volume (total of tubing and annular space around probe tip) was calculated based on the following equation: Volume = rrxr2xh Where: rr = 3.14159 (unitless) r= radius of sampling tube or annular space around probe h = length of sampling tube or height of annular space; 3. Based on step purge test results from previous sampling events at the BSC CVS, it was determined that no significant difference existed between the VOC concentrations in step purge volume samples. As such, and with the concurrence of the on-site MDEQ representative, a default of three to five purge volumes was used for all vapor sample collection. 4. After purging, a one-liter sample was collected from the vapor probe. 5. A hand-held photoionization detector (PID) sensitive to VOC concentrations in the range of 1 ppb (e.g., a ppbRAE model 3000 or equivalent) was used to measure the VOC concentration in the one liter sample. The purge volume VOC concentration was measured using a hand-held PID for the collection of all vapor samples. Samples were collected in SIM-certified SummaTM canisters. A flow regulator was placed between the probe assembly and the SummaTM canister to ensure that the canister was filled at a flow rate of 83 milliliters per minute in the first round of sampling 73766/SEA10R091 Page 12 of 23 October 26, 2010 KLEINFELDER 14710 NE 871'Street,Suite A100,Redmond,WA 98052 p J 425.636.7900 f l 425.636.7901 (which yields a sample collection time of one hour), and, in the second round of sampling, at a flow rate of 167 milliliters per minute (which yields a sample collection time of 30 minutes). Leak detection during sample collection was performed by covering the vapor probe and SummaTM canister/flow controller assembly with a plastic shroud and filling the shroud with a helium atmosphere. The shroud has two ports: one used to fill the shroud with helium, and one for a hand-held helium detector to monitor the atmosphere of the shroud during sample collection. The atmosphere within the shroud was maintained at 90% to 95% helium in the first round of sampling. With the approval of MDEQ, the helium atmosphere was reduced to approximately 25% in the second round of sampling to reduce the volume of helium used. MDEQ found on another project that a helium atmosphere of approximately 25% was adequate for a successful leak detection program. Sub-slab vapor samples were analyzed for helium to evaluate potential atmospheric leakage and the potential for sample dilution should leakage occur during collection. Helium concentrations less than 10% were considered acceptable (ITRC, 2007). Duplicate sub-slab vapor samples were collected for the evaluation of data quality at a rate of approximately one duplicate sample for each 10 sub-siab vapor samples. Upon completion of all sampling and with MDEQ approval, the sub-slab vapor probes were properly decommissioned. Specitically, the vapor probe assembly was removed from the boring and the boring was sealed with bentonite and a quick-setting concrete patch. In some cases, the vapor probe could not be removed so the Teflon""' tubing was detached and the brass probe was left in place. The boring was then filled with bentonite to just below the surface of the foundation slab and the floor was patched with quick-setting concrete. 2.7 SAMPLE ANALYSIS AND DATA VALIDATION All SummaTM canisters were shipped to ATL in Folsom, California for analysis by ASTM Method D-1946 for helium to address the potential for atmospheric leaks and by EPA Method TO-15 using GC/MS in full-scan mode for PCE and chloroform in the first round of sampling, and for PCE only after the second round of sampling. Lower detection limits necessary for PCE and chloroform were achieved by using a lei/Lo instrument that allows analysis by TO-15-LL and TO-15-SiM and concurrentiy achieves detection limits lower than TO-15-SI.M. The kaboratory reporting limits for PCE were in the range of 0.25 lag/m3 and for ail analyses were less than the EPA residential indoor air RSL of 0.41 lag/m3. The laboratory reporting limits for chloroform were as low as 0.14pg/m3 and, 73766/SEA10R091 Page 13 of 23 October 26, 2010 KLEINFELDER 14710 NE 874h Street,Suite A100,Redmond,WA 98052 p J 425.636.7900 f l 425.636.7901 therefore, were slightly higher than the EPA residential indoor air RSL of 0.11 pg/m3. After the first round of sampling, MDEQ determined that chloroform was not a chemical of concern for vapor intrusion (MDEQ 2010); therefore, analysis was not performed for chloroform in samples collected during the second round of sampling. Laboratory analytical protocols and reporting limits are provided in the MDEQ-approved work plan for this project (Kleinfelder 2009e). The data validation program that the analytical laboratory implemented is summarized as follows: • Assess accuracy and completeness of laboratory narrative • Assess analysis and reporting against the project profile and standard operating procedure requirements • Document corrective actions • Document unusual circumstances • Verify achievement of quality control criteria • Verify sample dilution factors • Verify appropriate peak integration and document manual integration • Verify that data flags are appropriate • Verify sample identification numbers against chain-of-custody Verify reporting list, units, and report header information Verify sample holding times Verify adherence to analytical sequence clock times Verify appropriate initial calibration Verify sample reporting limits Manually verify one sample result from raw area counts The laboratory performed a Level IV data review described as, "[a] management review by a director, department manager, team leader, or approved peer [which includes] a review to ensure the accuracy of the final hardcopy or electronic report. Data integrity surveillance checks [will be] performed at this level." Kleinfelder also performed a separate independent data validation (Appendix B) in accordance with the QAPP (Kleinfelder 2009e) prepared for this project. 73766/SEA10R091 Page 14 of 23 October 26, 2010 KLEINFELDER 14710 NE 87' Street,Suite A100,Redmond,WA 98052 p J 425.636.7900 f l 425.636.7901 2.8 HANDLING AND SHIPPING OF AIR SAMPLES After air samples were collected, the SummaTM canisters were placed, with the completed chain of custody form, inside the shipping box provided by the analytical laboratory. The box was taped closed with an appropriate shipping quality packing tape and shipped to the analytical laboratory by an overnight delivery service. 2.9 COLLECTION OF WEATHER DATA Weather data were collected each day of indoor and outdoor air sample collection to assess meteorological conditions that could affect sample collection and analytical results. The weather data collected included: wind speed, wind direction, temperature, relative humidity, barometric pressure, and rainfall. These data were collected using a Davis Vantage Pro2TM Weather Station placed at the former BSC. Meteorological data are provided in Appendix C. Weather conditions did not appear to affect sample collection or data quality based on the consistency and low level of variability in the data collected in the first and second rounds of sampling. 2.10 ACCESS ARRANGEMENTS Prior to indoor sampling, representatives of the City and CVS met with all owners and/or residents of the target structures and negotiated access agreements. The City and CVS were unable to contact several primary target structure owners, and several primary target structure owners opted not to participate in the study, and in these cases alternate structures were selected. 2.11 SAMPLE LABELING AND IDENTIFICATION All samples collected from the Residential Study Area were labeled as follows: Each sample identification label had four components corresponding to the collection area, structure address,. sample type, and sample number. The collection area was the Residential Study Area. The address of each structure was coded as follows: a house at 409 N 16th Avenue was coded as "16-409." Sample type was coded as: Indoor Air (IA), Outdoor Air (OA), Sub-slab (SS), or Soil Vapor (SV). Indoor air (IA) samples was further identified by the floor level at which it was collected, thus, basement floor samples was identified as "0," first floor was "1," and second floor was "2." 73766/SEA10R091 Page 15 of 23 October 26, 2010 KLEINFELDER 14710 NE 81" Street,Suite A100,Redmond,WA 98052 p l 425.636.7900 t l 425.636.7901 Thus, for example, the indoor air sample collected from the second floor of the home at 409 N 16th Ave was coded as follows: "RSA-16-409-IA-2." A sub-slab vapor sample from the same structure would be coded as, "RSA-16-409-SS-0." Duplicate samples were coded to prevent identification by the laboratory. The following format was used: "DUP-(six digit date)-(sample type); for example the duplicate for sample RSA-16-409-IA-1 collected on January 29, 2010 was coded as DUP-012910-IA. The primary and duplicate samples were cross-referenced on the field data sheets provided in Appendix D. Outdoor air samples did not have an address but were identified as OA-# and the field notes provide an approximate address, e.g., "intersection of N 16th Avenue and Durston Road." 73766/SEA10R091 Page 16 of 23 October 26, 2010 KLEINFELDER 14710 NE 871'Street,Suite A100,Redmond,WA 98052 p 1425.636.7900 f 1425.636.7901 3.0 RESULTS AND DISCUSSION Twenty homes and one commercial structure were selected for the investigation from approximately 101 homes and five commercial structures in the Residential Study Area north of the BSC site (Figure 6). The structures were selected by MDEQ, ATC, and Kleinfelder to provide a spatially-representative sampling program and to represent the various design configurations of the homes and businesses in the RSA (Figure 7). For ease of identifying structures and their design (e.g., presence of crawl spaces, slab foundations, number of floors), each structure is identified on Figure 6 with a letter (A- F). The letter refers to the structure design as shown on Figure 8. One sub-slab soil vapor sample (SS) was collected from each structure, except 16- 314(C), which had a crawlspace (CS) only. Indoor air samples (lA) were also collected from each floor in every structure and from the crawlspace if a crawlspace was present. The first round of samples was collected in January 2010. A second round of samples was collected in March 2010 from a sub-set of the identified structures based on a decision-making framework developed by the Montana Department of Environmental Quality for the evaluation of vapor intrusion (Table 1, Appendix E). The PCE concentrations in each sample collected in January 2010 and March 2010 are presented in Table 1. Complete analytical laboratory reports are presented in Appendix F. Sub-slab soil vapor concentrations ranged from not detected (reporting limit, 0.3 pig/m3) to 360 pig/m3. An obvious spatial pattern to the range of soil vapor concentrations could not be discerned. For example, the highest sub-slab soil vapor concentrations of PCE (360 pag/m3) were observed under the home designated, 17-512(A), located near the north boundary of the RSA and one of the four structures furthest from the source area on the shopping center site. The next highest sub-slab soil vapor concentrations of PCE (300 paglm3) were observed under the one commercial structure that was sampled, B-1 E02(E), and is located adjacent to the shopping center site. Sub-slab soil vapor concentrations of PCE between 17-512(A) and B-1602(E) ranged from 0.66 pig/m3 to 83 pg/m3. Sub-slab soil vapor concentrations of PCE appeared to be fairly consistent at a given structure when the results of the January 2010 and March 2010 sampling rounds were compared. Although order of magnitude differences were noted in three of the 12 73766/SEA10R091 Page 17 of 23 October 26, 2010 KLEINFELDER 14710 NE 87°i Street,Suite A100,Redmond,WA 98052 p 1425.636.7900 f 1425.636.7901 structures sampled in both January and March (4.1 lag/m3 to 26 lag/m3 at structure 17- 505(A); 0.57 lag/m3 to 4.9 lag/m3 at 18-310(A); and 5.3 lag/m3 to 30 lag/m3 at D-1526(B), in all other cases the difference between the January and March sample results are two-fold or less (Table 1). Evidence for seasonal fluctuations in sub-slab soil vapor PCE concentrations was not observed. In some structures, PCE concentrations increased between January and March but decreased between January and March in other structures. These results may indicate that sub-slab soil vapor conditions are relatively stable over time. There appeared to be no correlation between sub-slab soil vapor concentrations and indoor air concentrations (Table 1). For example, indoor air PCE concentrations in 16- 303(F), 16-402(A), 17-505(A), 17-512(A), 18-310(A), and B-1602(E) were roughly comparable despite sub-slab vapor concentrations that varied from 0.57 pg/m3 to 360 Ng/m3. The range of indoor air PCE concentrations was from not detected at a reporting limit of 0.23 lag/m3 to a maximum concentration of 36 lag/m3. Four structures appeared to have potential indoor sources of PCE, including 15-415(B), 17-411(D), 17-416(D), and 18- 418(D). In 15-415(B), the indoor air concentrations of PCE exceeded the sub-slab vapor concentration, and the upper floors had a higher concentration than the basement (Table 1). MDEQ did not require 15-415(B) to be resampled because an indoor air source is generally suspected in structures where the indoor air concentrations of PCE exceed the sub-slab vapor concentration, and the upper floors have higher PCE concentrations than the lower floors, including the basement. The indoor air concentrations of PCE in structure 17-416(D) also were higher in the upper floor than the lower floor, basement, and crawlspace. Because the sub-slab concentration of PCE was greater than the highest indoor air concentration, MDEQ identified 17-416(D) for resampling. However, the structure owner declined to have the structure sampled a second time and MDEQ did not require that it be resampled. The indoor air concentrations of PCE in structure 17-411(D) were higher in the upper floor than the lower floor, basement, and crawlspace. MDEQ required that 17-411(D) be resampled because the subslab concentration of PCE was greater than the highest indoor air concentration. During the March sampling, PCE was detected on the highest floor at 15 lag/m3, compared to 1.8 lag/m3 in January. As a follow-up, ATC contacted the structure owner and discovered that the owner had placed a recently dry cleaned item 73766/SEA10R091 Page 18 of 23 October 26, 2010 KLEINFELDER 14710 NE 87 h Street,Suite A100,Redmond,WA 98052 q l 425.636.7900 f l 425.636.7901 in an upstairs closet. MDEQ agreed that this likely represented an indoor air source and did not require additional action. The indoor air PCE concentration detected in 18-418(D) was 36 pg/m3. A review of the chemical inventory for this structure identified that an indoor source (e.g. break cleaner) of PCE was stored in a basement closet. MDEQ agreed that this likely represented an indoor air source and did not require additional action. The maximum indoor air PCE concentrations in the four structures described above (15- 415(B), 17-411(D), 17-416(D), and 18-418(D)) ranged from 5.5 pg/m3 to 36 pg/m3. The maximum indoor air PCE concentration in the remaining structures was 1.7 pg/m3. PCE concentrations in four outdoor air samples collected concurrently with indoor air samples on each of the four sampling days (one outdoor air sample per day) ranged from not detected (<0.24 pg/m3) to 0.46 pg/m3. The maximum outdoor PCE concentration exceeded the MDEQ indoor air screening level of 0.41 pg/m3. The significance of the indoor air concentrations of PCE was addressed by comparison to the SSCL for indoor air developed by MDEQ (2010). The SSCL is a health risk- based concentration of PCE in indoor air that yields a cancer risk of 1 x 10-5. MDEQ considers 1 x 10"5 to be an acceptable cumulative lifetime risk level for exposure to carcinogens because the Montana legislature has established water quality standards based on the 1 x 10-5 point of departure (MSE 2001). The SSCL for PCE concentrations in residential indoor air is 4.4 pg/m3 and in commercial indoor air is 22.3 pg/m3 (MDEQ 2010). Thus, concentrations equai to or less than the SSCL do not result in an unacceptable risk and do not trigger further investigation, mitigation, or remediation. In all structures where an indoor source of PCE had not been suspected or identified, the indoor air concentration of PCE was less than 4.4 pg/m3; therefore, MDEQ determined it will not require further action to address subsurface PCE vapors in the Residential Study Area at this time. 73766/SEA10R091 Page 19 of 23 October 26, 2010 KLEINFELDER 14710 NE 87'"Street,Suite A100,Redmond,WA 98052 p l 425.636.7900 f l 425.636.7901 4.0 REFERENCES ATC. 2009a. 2008-2009 Bioremediation Pilot Test Report, Bozeman Solvent Site, Bozeman, Montana, ATC Associates Inc., Bozeman, Montana, September 10. ATC. 2009b. 2008 Electronic mail from Michael Ellerd (ATC) to Kate Fry (MDEQ), Subject: BSS June GWM Lab Reports, ATC Associates Inc., Bozeman, Montana, July 16. Cal/EPA (California Environmental Protection Agency). 2003. Advisory — Active Soil Gas Investigation. Jointly issued by the Regional Water Quality Control Board, Los Angeles Region and the Department of Toxic Substances Control. January 28, 2003. [www.dtsc.ca.gov/PublicationsForms/index.html] DTSC (Department of Toxic Substances Control). 2004. Interim Final Guidance for the Evaluation and Mitigation of Subsurface Vapor Intrusion to Indoor Air. December 15. Revised February 7, 2005. EPA. 1994. Environmental Response Team, Standard Operating Procedures #2008: General Air Sampling Guidelines. November 16. EPA. 1995. Environmental Response Team, Standard Operating Procedures #1704: Summa Canister Sampling. July 27. EPA. 2002. OSWER Draft Guidance for Evaluating the Vapor Intrusion to Indoor Air Pathway from Groundwater and Soils (Subsurface Vapor Intrusion Guidance). EPA 530-D-02-004. Office of Solid Waste and Emergency Response, Washington DC. November. EPA. 2008. Regional Screening Levels (RSL) for Chemical Contaminants at Superfund Sites. Available at www.epa.gov/region09/superfund /prg/index.html. Accessed: April 15, 2009. EPA. 2009. Regional Screening Levels (RSL) for Chemical Contaminants at Superfund Sites. Available at MDEQ's website at: http://deq.mt.gov/StateSuperfund/pdfs/200904rsimaster.pdf. 737661SEA1 OR091 Page 20 of 23 October 26, 2010 KLEINFELDER 14710 NE 87"'Street,Suite A100,Redmond,WA 98052 p1425.636.7900 f1425.636.7901 EQM. 2004. User's Guide for Evaluating Subsurface Vapor Intrusion into Buildings. Prepared by Environmental Quality Management, Inc., Durham, North Carolina. Prepared for Industrial Economics Incorporated, Cambridge, Massachusetts under EPA contract 68-W 01-058. June 19. ITRC. 2007. Technical and Regulatory Guidance, Vapor Intrusion Pathway: A Practical Guide, Interstate Technology & Regulatory Council Vapor Intrusion Team, Washington, D.C., January. Kleinfelder. 2007. Sail Vapor and Indoor Air Survey Work Plan, Bozeman Solvent Site, Bozeman, Montana. Prepared for the City of Bozeman and.Montana CVS Pharmacy LLC. Prepared by Kleinfelder West, Inc., Bellevue, Washington. June 22. Kleinfelder. 2008. Soil Vapor and Indoor Air Survey Field Investigation Report, Bozeman Solvent Site, Bozeman, Montana. Kleinfelder, Inc., Bellevue, Washington, January 31. Kleinfelder. -2009a. Off-site Soil Vapor Survey, Field Investigation 'Report, Bozeman Solvent Site, Bozeman, Montana. Prepared for the City of Bozeman and Montana CVS Pharmacy LLC. Prepared by Kleinfelder West, Inc., Redmond, Washington, September 11. Kleinfelder. 2009b. Follow-up Soil Vapor and Indoor Air Survey Field Investigation Report, Bozeman Solvent Site, Bozeman, Montana. Kleinfelder, Inc., Redmond, Washington, June 10. Kleinfelder. 2009c. Revised Off-Site Soil Vapor Survey Work Plan, Bozeman Solvent Site, Bozeman, Montana, Kleinfelder West, Inc., Redmond, Washington, June 1. Kleinfelder. 2009d. Off-site Indoor Air, Sub-Slab Vapor, and Outdoor Air Investigation Work Plan, Bozeman Solvent Site, Bozeman, Montana. Prepared for the City of Bozeman and Montana CVS Pharmacy LLC. Prepared by Kleinfelder West, Inc., Redmond, Washington. October 26. Kleinfelder. 2009e. Quality Assurance Project Plan, Off-Site Soil Vapor Investigation,, Bozeman Solvent Site, Bozeman, Montana. Prepared for the City of Bozeman and Montana CVS Pharmacy LLC. Prepared by Kleinfelder West, Inc., Redmond, Washington. March 9, 2007, Revised June 11, 2009. 73766/SEA10RD91 Page 21 of 23 October 26, 2010 KLEINFELDER 14710 NE 87"'Street,Suite A100,Redmond,WA 98052 p1425.636.7900 f1425.636.7901 Maxim Technologies. Inc. 2005. June 2005 Soil Gas Survey Report, Bozeman Solvent Site, Bozeman, Montana. September 19. Maxim Technologies. Inc. 2006. 2006 Expanded Soil Gas Survey Report, Bozeman Solvent Site, Bozeman, Montana. May 8. MDEQ. 2009a. Letter from Cynthia Brooks (MDEQ) to Jeni Reece (City of Bozeman), Susan Phillips (CVS) and Ron Waterman (CVS), Re: Bozeman Solvent Site, Montana Department of Environmental Quality, Helena, Montana, March 11. MDEQ. 2009b. Electronic mail from Kate Fry (MDEQ) to Scott Dwyer (Kleinfelder), Subject: Bozeman Solvent Site Residential Indoor Air Concerns, Montana Department of Environmental Quality, Helena, Montana, February 25. MDEQ. 2009c. Letter from Kate Fry (MDEQ) to Michael G. Ellerd (ATC) and Scott D. Dwyer (Kleinfelder), Re: Revised Off-Site Soil Vapor Study Work Plan and Revised Quality Assurance Project Plan, Bozeman Solvent Site. Montana Department of Environmental Quality, Helena, Montana, June 5. MDEQ. 2009d. Letter from Cynthia Brooks (MDEQ) to Jeni Reece (City of Bozeman), Susan Phillips (CVS) and Ron Waterman (CVS), Re: Sampling Plan for Additional Vapor Intrusion Investigation for the Bozeman Solvent Site, Bozeman, Montana. Montana Department of Environmental Quality, Helena, Montana, September 4. MDEQ. 2009e. Letter from Kate Fry (MDEQ) to Scott D. Dwyer (Kleinfelder), Re: October 5, 2009 Work Plan for Residential and Background Indoor Air, Outdoor Air, and Soil Vapor Survey Work Plan, Bozeman Solvent Site. Montana Department of Environmental Quality, Helena, Montana, October 14. MDEQ. 2010. Baseline Risk Assessment Addendum — Off-site Indoor Air Site-specific Cleanup Levels, Bozeman Solvent Site. Montana Department of Environmental Quality, Helena, Montana, July 7. MSE, Inc. 2001. Final: Baseline Risk Assessment Work Plan For the Bozeman Solvent Site Bozeman, Montana. Prepared for Montana Department of Environmental Quality, Environmental Remediation Division, Helena, Montana. December. 73766/SEA10R091 Page 22 of 23 October 26, 2010 KLEINFELDER 14710 NE 87"'Street,Suite A100,Redmond,WA 98052 p1425.636.7900 f1425.636.7901 NEW 1996. Final Data Summary Report, Bozeman Solvent Site, Nicklin Earth & Water, Bozeman, Montana, June 7. NEW 1999. Final Phase Remedial Investigation Report, Bozeman Solvent Site, Final Report, Nicklin Earth &Water, Inc., Bozeman, Montana, September. RTI. 2006. Subslab Soil Vapor Sampling Related to Damaged Floor Tile, Hastings Books, Video and Music Store, Bozeman, Montana, Resource Technologies, Inc., Bozeman, Montana. December 10. 73766/SEA10R091 Page 23 of 23 October 26, 2010 KLEINFELDER 14710 NE 87"'Street,Suite A100,Redmond,WA 98052 p l 425.636.7900 f l 425.636.7901 2 < Q Q Q 0 o n n n n c H — cl) to d 10 O O O U) oo ��a N 0) C = N 3 (0 -D ()i N y to w (0 :3 '� O O Q CO cc U) a -a ox ��c � � c o c c � v � W —� i° cco s m a? 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Approx.Scale?n Feet www.klefnfelder.com 73765-Bozeman FiguresAw' Bozeman,Montana U) 1 I it Cf M C; CCMI N 1 5th Ave f ig -5 -4 CL v 10 Sv- > 15 S V-6 SV-7 i SV-2 44- Sv-1 —SV--1-2 71h e U) 0 0 -13 I F Cf) -attLA, Ln k CO � ) J 4i e_ Z r— ackmore PI E N 19th Ave i—9TH Ave-- _0 ir N 20th Ave 0 C) N 21 st Ave F-1 Brentwood Ave `J �� - -'� '; 22rtd Ave LL E L—N 23na LWoodland Dr Kirk Park 4:F E LUM Legend PROJECT NO. 73766 FIGURE a LL ag LU Soil Vapor Probe Locations a Soil Vapor Probe rV DRAWN: September 2009 June 2009 DRAWN BY: J.S. Th.Infor.W.Ind.thel this graphic representation has b— r LIJ LLI LU —and Is sublets to chmg 400 3 P1 df�=:E�j eamrandes.express or hpbd,,,-b or rights to t'hoounwa of 0 luCh InIorrratfion.This d-1 1,M Intended for use me rw convey pmdud I, SOAjddM CHECKED BY: S.D. 'designed or WendW me omatmcdort amen docurne"t.Th... the &f9ft PWPI&R19ft -nt Site FILE NAME Bozeman So!vL —kad ort this graphic rep—seom is w the sole dal,d the party using or.1sumv IZ -Int—dn. --- Approx.Scale in Feet www.kisinfolder.com 173766-Sozenan Figures.dwg Bozeman,Montana 1 1 r F SV-6 5' 10.5' I r Legend I c12DCE ND ND SV-5 5' 10, f ® Soil Vapor Probe III TCE 0.32 1.0 c12DCE ND ND I PCE 95 250 TCE ND ND � ; c'I 2DCE = cis-1 ,2 - Dichloroethene I — VC ND I ND PCE 59 350 TCE = Trichloroethene VC ND ND 05 a i-- PCE = Perch loroethylene (Tetrachloroethene) I I sv-11 5' ar I c12DCE ND ND SV-2 5' 11' VC = Vinyl Chloride -_- �� TICE ND 0.32 f c12DCE ND ND H _ PCE 70 180 TCE 1.5 2.4 © �-' VC ND ND PCE 1,400 1,100 VC ND ND SV-1 5' 10.5° I L c12DCE ND 0.765 � I --'- i -- -- — - SV-5 ' I I TICE 1.1 56 av r ; PCE 120 1,600 ° a _ N 16t' - SV-15 �, ver —_ s vc ND ND SV-6 I I N + ` r SV-7 SV- SV-2 ` ° --- ( — - . _ 1 7t ve SV-1 CO SV-15 5' I c12DCE ND 1 I ' I U M TCE 1.0 li IIII II U rail PCE 180 I i ��� ' 1 . th Ave I `� A VC ND J ' a' Black re > u ____ ____! J 19tr� Ave i c12DCE ND ND _-, 4ND N 19TH AvTCE ND 4.3 SV-4 5' 9.5' � PCE 4,100 1,700 SV-14 5' SV-13 5- 10' SV-12 5' 11' c12DCE ND ND VC ND NDO c12DCE ND c12DCE ND ND c12DCE NO ND TICE 1.3 4.2 N 20th Ave `�'-- TCE 0.98 0.41 TCE 0.44 0.25 TCE ND 0.32 PCE 660 890 - _ , PCE 160 240 PCE 30 120 PCE 150 230 VC ND ND - SV-8 5' 9.5' VC ND ND VC ND ND VC ND ND , -' c12DCE ND :ND TCE ND ND �+ ! sv-a 5' 10.5° p N 21 st Ave PeE 2.4 7.3 c12DCE ND ND -`---- --- i I VC ND ND © TCE 0.28 !�_ i ei I I PCE 85 150 ; LL Brentwood Ave _ VC ND ND SV-9 5' .1.5' _. �I J ---_— - - - ''` / '�. --__ i N 22nd Ave - f c12DCE ND ND L` - v v ��- TICE 0.72 7.6 cl a �- ` �_._.-- - > SV-10 5' 11' -- � PCE 53 f 110 mc12DCE ND NO __-.- - -- -----� - -;-- VC ND ND -- --fir— e I TCE 0.51 ND i m _r ,' I �_ I�23n Ave Woodland Dr � � � PCE ,8 39 --- Kirk Park � d --- - - ��' �. VC ND ND I \ \ E f I w i.. PROJECT NO. 73766 FIGURE OLL LU DRAWN: Ju 2009 SoiiJunVaor u1ts e 2 O9 O C 3 DRAWN BY: J.S. ,�m�pan°p dua�m�. ,° .sp�°pr��p�pp�a,mm.vwl*� rLE/NFEL�DER W W uj mu sd Is suhjera m dwW s,mom mom.KleWeleer makes no npraa.mamn.or 0 40Q _=J waaantles,mm us m Impuea,sa m--Y,amplmeness,II.Wass,or dnhb m me use of r_,�Y CHECKED BY: S.D. (�(� sum mm sue.es! a ,l,slu Is rm irnenam mr use ae a use nurser f the I ar Is n h•Ngft .aW t7Y W o. 4 4 r ae ansea ar mtesmw we sueewnoe asset aosumstx.mo use ur misuse of ms im°rmeuou '�.,� Bozeman Solvent Site wnmmea on nda nraphm rePma mhAlun Is at the sale dsk or the parry uWW m mT,,Arg the FILE NAME: W btf—aeon. Approx.Scale in Feet - www.kisinfolder.com Bozeman,Montana QQrn 73766-Bozeman Figures.dwg • j ��RMER BUTTREY :... . . - i SHOPPING CENTER - r. RESIDENTIAL STUDY AREA o j CS � ' �i '� t .f- s •1. . tl • cc 017 O of Ilk E gi R , ..I. _ t '� i t .J�4 r► �. ► �+ J � ~`• _ . � /�► wl:r' ' , . . - - N 19th Ave - - 'r' N 19TH Ave - ^- *� r� �� i c r , -'-: 00 0 ;r Ju L •, • '�y _ ^ • ,.• .. ••,..tiH•.1.1 I • { • �. ' • i •• 1`.� R�t��•w� . raw �. ' _ Q _ _C 'S• `� �� ( tr I r CL - -• : ram-. . Q 1 Joe �• • r' I ' "f O •• • '• i 4 • , A. a •• Ly, . . W �—; • � � re ., — d e : tom. r^': L .' CL E v • t Im E sASM t�ii rq PROJECT NO. 73766 FIGURE Q DRAWN: September 2009 proposed residential Seedy Area 1 _x 111 00 The Infmmalhn[W,ded an Nh graphic mpres•n -has t.en a•nvted from a.adely of DRAWN N BY: J.S. W W W aamaes and le aah�d m 0_9.whh.t neda..IO.Irdeldar na mPaamadona a 0 400 KLEWPEL DER � � 22 j r.—doe,.q—enplhd,asba Y,rampehneaa.gmellneea.mdghhtotheueaof �•w t D/1� CHECKED BY: S.D. V Q,j suCi Inhem"uon.Thh doamml is nal Imended fa aa•.a land aumay pmducl w ie it p.a..a - QQk dedgned.,Wendedasa.n=dondadgndxumentTheusemmisuseoftheIldan-Vanf �"•r � Bozeman Solvent Site :.,._.- - ,...' FILE NAME: ` Q �g an HMh graphlo.ep—toolon le a1 th coh dae W e•pady using a mhuahy dm A rcx.Scale in Feet '`�►w..�/'� Bozeman,Montana Q Q N PP waunv.kleinfelder.com 73766-Bozeman Figures.dwg E A , o l I N 0 13 - l Summary of Structures and Sample Types Collected CM i � Ris Add,ess.�..._._� _ indoor w° Flap# Cod®$ Sublet! Cravt�Espac�t AiEb * „ 1 15-319 D 1 1 I 3 r • 1 2 15-415(S 1_ NA _ _ ___2 ` 3 15-5©3 C) 16• 'll.'1 r . 4 16-303 1 NA 3 5 16-314 C NA 1 1 s� '� J ,�1► !'�'�" — 6 16-402 A 1 1 ; 2 .� 17 _ 7 _ _ 16 411(Bj • 1 NA 2 - - r 8 16-502 B I 1 NA - !►. $ 17 314 13� 1 NA �2 •r= . l 10 17•-315 D 1 1 1 .3 TM- t. ` 11 17-411 D 1 1 3 ''r .• - 12 17-416 D 1 1 3 ►; ' {'• - 13 17-505{A} 1 NA �2- ' r a" 14 17-512 A 1 NA 2 15 18-310 A 1 NA i 2 0 16 1814(A) f• _17 1E 418UD 1- 1 ' 3 - Sit- 18 18-503 C PIA 1 1 . _ _9 ,- 19 18-514 8 1 NA 2 ., �• �;� t �. . �, r -- '= zo 8-1602 E 1 NA I 711 21 D-1526 j�) 1 NA 2;= ,, r'! i � a Structure numbers are keyed to street addresses,e.g.,18-319 corresponds to the structure at 310 North ' _ •i., . 6 �- 15th Avenue.B-1 2 corresponds to 1602 W Bea9 Street. D-152e corresponds to 1526 Ourston Road.The letter in parentheses Indicates the stricture configuration as shown on figure& a e A t u Floors are living spaces such as the basement floor.ground or first floor,second floor,etc NA,not applicable. Where PIP,is noted for a sub•slab sample,.the structure did not have a concrete slab- VP on-grade foundation,thus a sub-slab sample could not be collected. Where NA is noted for a cr ce, •� the structure did not have a crawlspace and a cravrispace sample could not be collected. 01, r LL Olt, a E N " PROJECT NO. 73766 FIGURE 0LL u, �/'�� Strictures Selected for 2° < DRA�:,r,: July solo Indoor Air Testing x�+ BY: J.S. 0 sTh,ta cesan Is IndedM an Wb yre th rePresmdetlen f k been nnnpa r fmm a vatleq of �`�r`Yl Y� Yl 1! !t�L�► + W W_j somas and I:sugea k merge wmo�d notice.Nklyd.Her m.xn m rePreseMlakne or !r ! CC��U L7 G7 2 2 J wemMee,esP ev°r hnPlletl,as is a d y,mrepklem s ,Weld e,u rights to Na uw of I ,�,,,,L O� CHECKED BY: S.D. 4domelkn.Thb d°onnenl is cm klW. for eee a e uM wreey Prmud ror k it rwY•�'MN•` Qak deWgnedal,tar,dtleesconeWmendeygnd—srent The uaeorml6useafMudurmalkn Nato Scale Bozeman Solvent Site anlalrnd w Ws graphic represemelbn Is at the ada risk W u.PgH utlng m Msueing the I FILE NAME: �+..� Bozeman,Montana Q Q y www.klelnfelder.com Sample Schematic.dwg Z F W h LL M M NG W i,., -- W w L—L I H W F W W W W v I V m W WCA 3 Z O r Q I so li F ON ON t0 a ! I ON_ � ig co d o p ILI r_ ca N Q U C N N CID F ii \ cL E co CD WON M - M � M M I OW \ Ito J I - M O M (WD N ❑ F "'--'NG ass---^J1G S' _�Fx -. —er-- .\,•� � ee S ^ n� � z ✓ Z } m W Z Y Q c W W W r E \ 3�\ �� O ga W H r I i f LU 'e Flre co is o I 3EZ M M M M M I J I— M — M � LL CID LL t Ui' � � •N65�_NG - - -- I � o F Bgo€ U M rI I I -eEW� ItM M M M Il I I SS o;H! fff I s li M — m — M I ! c�S � iaa � C5 . T W w -_ ,._ M W W �I i�g €1,1a _ W W w W W -- w 2 �es8`agS _ W -- W ~� QLUW. j W E� W — W W Z Z s<eR�a ON II I I i f!I i � ^ W jl :;jo 22IIIIIIJ I I I I F W W �ja d w w E a r 15-415 A 16-402 16-411 C 0 17-505 IA-1 16-502 Z 17-512 17-314 0 IA-1 18-310 18-514 IA-1 15-503 CO N 18-414 D-1526 16-314 c 18-503 u! IA-0 , a CS !A-0 ` I IA-3 m IA-2 IA-2 15-319 F g 17-315 IA-1 17-411 17-416 IA-1 a IA-1 b IA-1 18-418 B- 1602 16-303 -7 IA-0 cs LL Is r CO Legend a SS Sub - Slab CS Crawl Space a IA-0 Indoor Air Sample from Basement 1 IA-1 Indoor Air Sample from Ground Floor E IA-2 Indoor Air Sample from Upper Floor PRQJECTNQ. 73766 FIGURE a� CA-3 Indoor Air Samp le from Upp oor er Fl Schematic Diagrams of 9xa DRAWN: Jul �u�o Residential & Commercial Structures p p DRAWN BY: J.S. Thal and Is s b)M a e.Phbranodee.nm twas Nider m kes no r,mma.� y KLE/NFELL�E��W[L I sources and b sub�e<b tlwiBe wllhoul natice.IVelMeltler mats m regasenletlma w y S=J i Impledasb—.'.mmpbtmis,gm.brw,r"0bbthauseof CHECKED BY: S.D.ch Inrarmatbn.Thisdoeud b mt INarMatl for use es a laq survey product nw Is l _ t JVIYf/W�.eoslatlaIntended as a mnMctlm dVn tlar.Lmrt Th.use ar abuse of iha Irdwmatbn Not toScale \��_ 1.+./� FILE NAME: Bozeman Solvent Site mnbYrE an We graphic represent dDn Is at the sale dek or the party using ar W..kV the Bozeman,Montana QH nbm.yart www.kleinfeldee.com SampleSchematic.dwg E APPENDIX A PRE-SAMPLING INSPECTION AND CHEMICAL INVENTORY FORMS KLEINFELDER 14710 NE 87'"Street,Suite A100,Redmond,WA 98052 p 1425.636.7900 f 1425.636.7901 .� .� r �� �i RESIDENTIAL/COMMERCIALfRETAIL QUESTIONNAIRE INDOOR AIR ASSESSMENT SURVEY This form must be completed for each building Involved in an indoor air investigation. Preparer's name 0L-CwUVeyAQ-u4--& _ o- Date prepared 1-- 12--10 Preparer's affiliation A-F - Telephone numbers- Z �J -/0 33 OCCUPANT: Name R1 C�"-J, Z,r�r'ce v� I Address f5 04 y--e— city Telephone number g6tV._ 5`b7-7d,33 What is the best time to call to speak with you? Are you the Mowner, ❑Renter, ❑Other of this Structure? Total number of occupants/persons at this location? Average daily occupant/visitor population: o� persons. Number of children?�{ _Ages? Flow long have you occupied this location? O rg::!�- OWNER OR LANDLORD: Name (if different from occupant) Address Telephone number Land Use and Building Construction 1. Type (Check appropriate responses): gResidential ❑Commercial ❑Office ❑Warehouse ❑Strip Mall 2. Age of the building? r years. 3. Number of floors (stories) 1 4. Area of the building (square feet) 5. Is the building insulated? N Yes No J 6. How well is the building sealed? 7. Number of elevators in the building IVA- 8. Condition of the elevator pits (sealed, open earth, etc.) AIA 9. Above-ground structure construction materials(check all that apply): RDNood Brick ❑Concrete ❑Cement block _ ❑Other nn�eyY�w t 10. General description of building construction materials Pva 11. Does the building have windows that can be opened? Yes ❑No 11 a. If YES, indicate number and ype(s) of window(s): aA -e 11 b. If YES, describe the freque cy and duration of window opening: 12. Does the building have doors? Yes No 12a. If Y S, indicate number and type(s) of door: 12b. If YES, describe frequency and duration of door opening: 13. Foundation Construction (check all that apply): Noncrete s6ib. -grads-- ❑Fieldstone ❑Concrete block LJElevated above ground/grade ❑Full Basement Crawispace 'LjOther [NOTE: If the building does not have abasement, go to question 24.1 14. Basement? ,Yes, ❑No Crawl Space? Yes, ❑No - SLL 14a. If YES, under how much of the building floor space?,-I)D% 15. Is the basementogfnished, or❑unfinished? 16. If finished, how many rooms are in the basement? 13 16a. How many are used for more than 2 hours/day?.I" cr- 17. Composition of basement floor(check all that apply) Concrete Tile ®Carpeted ❑Dirt ❑Wood ❑Other(describe) ? 17a. If concrete, is the floor E�Qaled 3 VyK; _mil � et�,&Wl afdXS nunnsealed Rainted afqj overed ❑Cracked ❑Other(please specify) 18. Are the basement/foundation walls oured concrete Cement block ❑Stone ❑Wood ❑Brick ❑Other ? 19. Are the basement/foundation walls Sealed �'�5 �a..�--t- � �" +�Oak Unsealed MUnknown � /��� �I / C. �, �" 20. Does the basement have a moisture or water infiltration problem (check one only)? ❑Yes, frequently (3 or more times/yr) ❑Yes, occasionally (1-2 times/yr) Yes, rarely (less than 1 time/yr) No 21. Does the basement ever flood(check one only)? ❑Yes, frequently (3 or more times/yr) ❑Yes, occasionally (1-2 times/yr) []Yes, rarely (less than 1 time/yr) JZNo 22. Does the basement have any of the following? (check all that apply) Floor cracks, p � Wali cracks — I d � 9,Sump Floor drain Other hole/open' L floor (describe) "V Lna (Identify all potential soil gas entry points and their size (e.g., cracks, voids, pipes, utility ports, sumps, drain holes, etc.), and any fluid accumulated. 23. Are any of the following used or stored in the basement(check all that apply) ,Paint ❑Paint stripper/remover 7Paint thinner rn _ ❑Metal degreaser/deaner ❑Gasoline ❑Diesel fuel ❑Solvents ZGlue Laundry spot removers Drain cleaners Pesticides Water and Sewage 24. What is the source of drinking water for the building (check all that apply)? ,Public water supply ❑Bottled water ❑Private Water Well. If private well, please answer following: ❑Drilled Well E]Driven Well []Dug Well E]Other (Specify) Afater Well Specifications (if applicable) Well Diameter Grouted or Jngrouted Well Depth Type of Storage Tank Depth to Bedrock Size of Storage Tank Feet of Casing Describe type(s) of Treatment ❑Other, please specify 23. Are there taste and/or odor problems with the water supply? ❑Yes, []fro If YES, please describe Wow long has the taste and/or odor problem been present? 24. Is the water chlorinated, brominated, or ozonated? ❑yes, ❑no, ❑unknown 25. Does the building have a private well for purposes other than drinking? Yes No If YES, please describe purpose of the well: 26. Does the building have a septic system? Yes 0 Not used ❑Unknown 27. How is sewage disposed? Public Sewer Septic ❑Tank ❑Leach Field ❑Other(Specify) 28. What is the distance from the water supply well to septic system (if applicable)? feet 29a. Are septic tank additives used? ❑Yes ❑No ❑Unknown. If so, what type? 29. Is there standing water outside the building (pond, ditch, swale)? El Yes No Heating, Ventilation, and Air Conditioning 30. Heating system fuel or power supply? Check all that apply: Natural Gas ❑Heating Oil ❑Kerosene ❑Solar ❑Electric ❑►Nova ❑Coal ❑Other 30a. Fla conveyance system: orced'hot air Heat Pump ❑Forced hot water ❑Steam ❑IRadlant floor heat ❑Wood stove ❑Coal furnace ❑Firep'sace ❑Electric Baseboard ❑Unvented Kerosene Heater ❑Other��Le -ar sue` ��' _ 31. Where is the heating system located? 32. Does the building have air conditioning? es ❑No Ja. If YES, please check the appropriate type(s) antral air conditioning ❑Window air conditioning unit(s) ❑Other, please specify 33. Does the building have any of the following? XRoom fans ❑Ceiling fans ❑Attic fans 34. Is the building ventilated using the fan-only mode of the central HVAC system? , sP4 ❑Yes a^dWrs i� )1.No 34a. If YES, What is the rated size of the fan? 35. Water Heater Type: [ZGas Electric ❑Other 36. Water heater location: (please describe) Potential Indoor Sources of Pollution 37. Has the building had termite or other pesticide treatment: Yes 0 Unknown 37a. If YES, please specify type of pest for which treatment was applied 37b. Approximate date of service 37c. Location of treatment within subject building 38. Has the building been recently (within the last six months) painted or remodeled? ❑,Yes 0 38a. If YES, pleases ecify what was done,where in the building, and when: - 39. Has new carpeting been installed in the building within the last year? ❑Yes /MVo 39a. If YES, when and where? 40. Is a dry cleaning service present in the building (check only one box)? ❑Yes, dry-cleaning performed on-site Yes, dry-cleaning sent off-site, drop-off only No YIW 41. Has the building ever had a fire? E]Yes 0 42. Are there any cooking appliances in the building? rum 1AAYes No 42a. If YES describ 43. Are the cooking appliances vented by use of exhaust hoods? Yes No 43a. Do the hoods vent to the outdoors? []Yes No 44. Is there an automatic dishwasher? M-yes ❑No 44a. If YES, is the dishwasher ❑Commercial grade;or Residential grade? 45. Is smoking allowed in the building? ❑Yes Po 45a. If YES, approximate number of smokers and level of smoking activity: (number of smokers) Light (<five cigarettes per day) Moderate (�five cigarettes per day) Heavy (one or more packs per day,>20 cigarettes per day) 46. Are air fresheners regularly used in the building? ❑Yes �21Vo 47. Are any of the following activities performed in the building? ❑Heating ❑Soldering ❑Welding - �i1rzZ o�� Ye—do ainting (b sh or oller) s4a•#rur� -- r�r rr P Painting (spray) Wood or metal finishing Other Wivity i volving chemical usage? (Please describe): 48. Please identify building cleaning and maintenance practices: Dusting Dry sweeping Vacuuming Polishing (furniture, etc) Washing er-waxing-ffee � l n4o arpet cleaningf cart ❑Other General building use of consumer products (please circle appropriate): Assume: Never = never used, Hardly ever = less than once/month, Occasionally = about once/month, Regularly = about once/week, and Daily = approximately once/day. Product Frequency of Use in Building Product Never Rarely Occasionally Regularly ©ail Spray-on deodorants I Aerosol deodorizers Insecticides Disinfectants Window cleaners X Spray-on oven cleaners Nall polish or remover Hairsprays Solvents/Degreasers Paint or paint remover Miscellaneous (specify) L 49. Other comments: Figures/Additional Information Plan View: Sketch each floor and if applicable, indicate air sampling locations, possible indoor air pollution sources, preferential pathways and field instrument readings. Potential Outdoor Sources of'Pollutlon: Draw a diagram of the area surrounding the building being sampled. If applicable, provide information on the spill locations (if known), potential air contamination sources (industries, service stations, repair shops, retail shops, landfills, etc.), outdoor air sampling locations, and field instrument readings. Also, on the diagram, indicate compass direction, locations of water wells, septic systems, and utility corridors if applicable, and a statement to help locate the site on a topographical map. Complete the attached Chemical Products Inventory Form Chemical Product Inventory Form Building Occupant 6w, L" Building Address -2,14 IS-4h Aue- City, State, Zip Code 7N , . Field Investigator r-y'% 11 Date Field Instrument Usedis C tit a pen :container';:;............. pan :M U"r e, c.a U & ..... . ....... 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I a °d N6. 1 e-dvf- Jo, j 4 y►clur� R1 0-L-. 0014.»WO,I14A Peez - Arm, j{ O-L- ��hn Seunou.r'�a►v�, "$(.cee.U�(_wi it 3a .�. y e a P -- N Ppiw 3�p dl- c �wrk r Va" doq hf' 014' 3a a� 5hke,due--.<�;�' A) ^46 crc U3�, ► Sc Zoo 'Ake 5,4,111h dJ 156 DXo BY to Fria,d& g• G, fir' `d 'S / � �a bar* siz�_,4 Fwdx 13D al ��4 Al NO fly �� ��- ��,E,-�.'�.,;�-��j�� ff� Chemical Product Inventory Form) Building Occupant � �-r` Building Address City, State, Zip Code Field Investigator c24JL�l Date I -- / - Field Instrument Used Product Description (commercial'name, quantity Volatile Ingredients in the dispenser type, container Product size, manufacturer, etc.) 1 1[4"u 1-ate wr Atil 16 d � g fla4410 - I a V Cl ZD bwtw 64dbe-1. 4 I � Lv ') Ili So �` 0,04 P 'a n 1 1 krPufi-oA Wiry -e c� az bai�cvlew� 04"- Chemical Product Inventory Form Building Occupant * Lillm U04 Building Address ^ ve' City, State, Zip Code Field Investigator Date Field Instrument Used N Product Description (commercial hame, volatile Ingredients in the dispenser type, contalner Quantity Product . size manufactu er, etc.) i ]j'fe hat ` kh, (" /hoof a Qa�eV' o� 3 rv � ar - 30-� Aon!!,, 'q U 2 s r� )(Z_ /q' Kd6X'C 1 , ewti; a, - z t- W00A dwiA /6 o"z- F1-710--04 iMltJcyl: �L.1� lw o'!Yw 1 It' h ACC 1 11, f-�'ii.St �pna ►1� rya(�6G�tr' i+ V 1 n!/ Amjg ll."� 3t B'L i /aC6 rkd -5* �i,7orGc� dra►� Brie ��'�z. 1415co xl,:, 1 b 07, try Iwt �.�� ��� ���►� �+ (�a� , Y 1ky/1 9/1.55 eoe -t G I'a0��' S r+ysnk del-A- rd 'Ji, rt I'll k OW r", AS! W,o -J,!le bZ Rv,s� ole t Wl yen-e4o ( 3/tj A6 I1Osipc c%e&cr• Q,� 7- 02. f�urlts .544c vz„ 4-0 U �r Qr i/ro G,vwd. 6 p/y, z Zro% Chemical Product Inventory Form I/ Building Occupant ''°p '' `fir. e! Building Address -1 City, State, Zip Code- -ji ag& eAr , A Z7'- Field Investigator LN l k- Date )- ► --►& Field Instrument Used Product Description (ccimmercial name, Volatile Ingredients in the dispenser type, container (quantity Product size, manufacturer,etc. ACE; zor, 1' �Cr a) Vl /{{11 �� ��f• e /r , X,Ile r•- 1 aleti r(k �W dog ow- a co 06-e:e.1 AoA U64 ea"I.Wyy;v o� . r f/ .tt_ 32 v- '6'.A •a AUd AMS Ale, 32 n� ALAFa Whkr C�441 A 2.. D 1 All o� �A,zp+/ 11'F� A"r W v GCS TaC( Q y, r y SM worm, i � i I 1I4 i Ln--4 : �-: Ar: s� � t ,. . TIP N r : .. .�� -•--�1 Yam— • i t RESIDENTIALICOMMERCIALIRETAIL QUESTIONNAIRE INDOOR AIR ASSESSMENT SURVEY This form must be completed for /each building involved in an indoor air investigation. Preparer's name eole �YlN �l&� AualaiDate prepared Preparer's affiliation *-rC- Telephone number ( OCCUPANT: Name JML Address y t J Ave- City -)3I Telephone numbers What is the best time to call to speak with you? Are you the WOwner, ❑Renter, ❑Other of this Structure? II Total number of occupants/persons at this location? Average daily occupant/visitor population: OV4, persons. Number of children? Ages? How long have you occupied this Iodation? OWNER OR LANDLORD: Name o ". "A-c--- (If different from occupant) Address Telephone number Land Use and Building Construction 1. Type (Check appropriate responses): Residential Commercial ❑Office ❑Warehouse ❑Strip fall 2. Age of the building? ! '% years. 3. Number of foors (stories) 4. Area of the building (square feet) __1 20 60 5. Is the building insulated? UqYes ❑No 6. How well is the building sealed? r. Number of elevators in the building !trE 8. Condition of the elevator pits (sealed, open earth, etc.) /111 9. Above-ground structure construction materials (check all that apply): Riood ck ❑Concrete ❑Cement block ❑Other 10. General description of building construction materials 11. Does the building have windows that can be opened? Yes NN o 11a. if ES, indicate number andtype(s) of window(s): /r 1 11 b. If YES describe the frequency and duration of window opening: t„ !il7�i ra4-i 12. Does the building have doors? Yes ❑No 12a. If YES, indicate number and type(s) of door: 3 ��-t-acv 12b. If YES, describe frequency and duration of door opening: 13. Foundation Construction (check all that apply): Concrete slab on grade Fieldstone ❑Concrete block ❑Elevated above ground/grade ❑Full Basement ❑Crawlspace ❑Other [NOTE: If the building does not have a basement, go to question 24.] 14. Basement?Kyes, ❑No Crawl Space? Yes, WNo 14a. If YES, under how much of the building floor space?/O-O % 15. Is the basementpfinished, or❑unfinished? 16. If finished, how many rooms are in the basement? q.t. 1&(ah f3 16a. How many are used for more than 2 hours/day? aA 44) /�oYI 17. Composition of basement floor(check all that apply) Concrete The Carpeted Dirt Wood • Other(describe)_ ? 17a. If concrete, is the floor ❑Sealed ff Unsealed ainted ❑Covered ❑Cracked ❑Other(please specify) 18. Are the basement/foundation wails R oured concrete ement block ❑Stone ❑Wood ❑Brick ❑Other ? 19. Are the basement/foundation walls ❑Sealed ❑Unsealed XUnknown 20. Does the basement have a moisture or water infiltration problem (check one only)? MYes, frequently(3 or more times/yr) Yes, occasionally (1-2 times/yr) ❑Yes, rarely(less than 1 time/yr) oar -19-f- ►� ❑No J 21. Does the basement ever flood (check one only)? ❑Yes, frequently (3 or more times/yr) i�Yas, occasionally (1-2 times/yr) Yes, rarely(less t art 1 tine/yr) �O '� e�r3 'N.' la.,orwk INo 22. Does the basement have any of the following? (check all that apply) ❑Floor cracks, ❑Wall cracks ❑Sump ERFloor drain P6-Te ❑Other hole/opening in floor (describe} (Identify all potential soil gas entry points and their size (e.g., cracks, voids, pipes, utility ports, sumps, drain holes, etc.), and any fluid accumulated. 23. Are any of the following used or stored in the basement(check all that apply) MPaint E4haint stripperlremover ❑Paint thinner ❑Metal degreaser/cleaner ❑Gasoline ❑Diesel fuel ❑Solvents ❑Glue I ❑Laundry spot removers Drain cleaners Pesticides Water and Sewage 24. Ahat is the source of drinking water for the building (check all that apply)? ublic water supply Bottled water ❑Private Water Well. If private well, please answer following: ❑Drilled Well ❑Driven Well ❑Dug Well ❑Other(Specify) Water Well Specifications (if applicable) Well Diameter Grouted or Ungrouted Well Depth Type of Storage Tank Depth to Bedrock Size of Storage Tank Feet of Casing Describe type(s) of Treatment ❑Other, please specify 23. Are there taste and/or odor problems with the water supply? ❑Yes, ❑No If YES, please describe How long has the taste and/or odor problem been present? 24. Is the water chlorinated, brominated, or ozonated? ❑yes, ®no, ❑unknown 25. Does the building have a private well for purposes other than drinking? Yes kNo If YES, please describe purpose of the well: 26. Does the building have a septic system? ❑Yes 0 Not used ❑Unknown 27. !-low is sewage disposed? Public Sewer Septic ❑Tank ❑Leach Field ❑Other(Specify) 28. What is the distance from the water supply well to septic system (if applicable)? feet 28a. Are septic tank additives used? ❑Yes ❑No ❑Unknown. If so, what type? 29. Is there standing water outside the building (pond, ditch, swale)? Yes 0 Heating, Ventilation, and.Air Conditioning 30. Heating system fuel or power supply? Check all that apply, Natural Gas ❑Heating Oil ❑Kerosene ❑Solar ❑Electric ❑Wood ❑Coal `� 15�- I �Ofher,�.� Lti 30a. Heat conveyance system: Forced hot air Heat Pump ❑Forced hot water ❑Steam ❑Radiant floor heat Wood stove Y p• ]Coal furnace ❑Fireplace ❑Electric Baseboard ❑Unvented Kerosene Heater ❑Other 31. Where is the heating system located?_ P'.v"U� 32. Does the building have air conditioning? NYes No 32a. If YES, please check the appropriate type(s) Central air conditioning Window air conditioning unit(s) ❑Other, please specify 33. Does the building have any of the following? NRoom fans ®'Ceiling fans ❑Attic fans 34. Is the building ventilated using the fan-only mode of the central HVAC system? Yes No 34a. If YES, What is the rated size of the fan? 35. Water Heater Type: Gas Electric ❑Other 36. Water Beater location: (please describe) Potential Indoor Sources of Pollution 37. Has the building had termite or other pesticide treatment: ❑Yes No ❑Unknown 37a. If YES, please specify type of pest for which treatment was applied 37b. Approximate date of service 37c. Location of treatment within subject building 38. Has the building been recently (within the last six months) painted or remodeled? []NoR 38a. If YES please sp ci whaI was done, where in the building, and when 39. Has new carpeting been installed in the building within the last year? Yes No 39a. if YES, when and where? 7baJ" 40. Is a dry cleaning service present in the building (check only one box)? ❑Yes, dry-cleaning performed on-site es, dry-cleaning sent off-site, drop-off only o 41. Has the building ever had a fire? ❑Yes gNo 42. Are there any cooking appliances in the building? 9Yes ❑No 42a. If YES, describe: 43. Are the cooking appliances vented by use of exhaust hoods? Yes No 43a. Do the hoods vent to the outdoors? 54yes No 44. Is there an automatic dishwasher? JAYes, No 44a. If YES, is the dishwasher [—]Commercial grade, or Residential grade? 45. Is smoking allowed in the building? ❑Yes �JNo 45a. If YES, approximate number of smokers and level of smoking activity: (number of smokers) ___Light (<five cigarettes per day) Moderate (>five cigarettes per day) Heavy (one or more packs per day, >20 cigarettes per day) 46. Are air fresheners regularly used in the building? RYes ❑No 47. Are any of the following activities performed in the building? Heating Soldering Welding Fainting (brush or roller) KPainting (spray) �- ❑Wood or metal finidiing17 ❑Other activity involving chemical usage? (Please describe): 48. Please identify building cleaning and maintenance practices: 9busting Rn IrL.IlDry sweeping acuuming Polishing (furniture, etc) Washing or waxing floors Carpet cleaning Other G' General building use of consumer products (please circle appropriate): Assume: Never = never used, Hardly ever = less than oncelmonth, Occasionally = about once/month, Regularly = about once/week, and Daily = approximately oncelday. Product Frequency of Use in Building Product Ne er Rarely Occasional) Re ularl Dail Spray-on deodorants Aerosol deodorizers Insecticides r Disinfectants Window cleaners " $ Spray-on oven cleaners Nail polish or remover Hairsprays - Solvents/De reasers Paint or paint remover Miscellaneous (specify) IJ' 49. Other comments: Figures/Additional Information Plan!flew: Sketch each floor and if applicable, indicate air sampling locations, possible indoor air pollution sources, preferential pathways and field instrument readings. Potential Outdoor Sources of Pollution: Draw a diagram of the area surrounding the building being sampled. If applicable, provide information on the spill locations `if known), potential air contamination sources (industries, service stations, repair shops, retail shops, landfills, etc.), outdoor air sampling locations, and field nstrument readings. Also, on the diagram, indicate compass direction, locations of water wells, septic systems, and utility corridors if applicable, and a statement to help locate the site on a topographical map. Complete the attached Chemical Products Inventory Form Chemical Product Inventory Form Building Occupant- + Building Address City, State, Zip Cod Field Investigator rr,. Date L-9-10 Field Instrument Used- n -`�.-Molat! I n gr..e...d..,q a-.. uan i 'Product ........... :diispense ze..'manufacturer J QfA MO n A I;v-eN(A PI"5 OTI 8 0 a!5� 19 Cb V7 cr-t- GOo OfV 1W1f11$ %,V% was .3 7- ol, Tile).7 , P4 lUak AA r U&-Z "C), 61- P-Rn W-111- 1UO1V-C_ CVr 6-t- 6- I&ITr* 6j ftdq�, kzvdalisitt3 di' l ko fiE M ,�" &aras64 6 Oxi II 9� �/ L (3 kmk 1 16 5 6--z_ :219-95 64; Chemical Product Inventory Form '),V1 Building Occupant Sf.44 `1 -aAM aAA)SCIYI Building Address q 127 1(;-it, qU e- City, State, Zip Code Field Investigator .(:s,-,l k- L.Q Date a /Z) Field Instrument Used . ........... it in uan ingredil6nts. Arne ......... ctdr9r.::btc-) sizG":manuTa k4-Atru lic FMA,M-01 . G t' I Le- Mle 2- 6-1: A0 6--L- 11 1 4C41411 02= P7oa,LnVW WLA41 2-6-4--AA ea- n . Md "A 6-�- DA z -r-.a A�-4 PIP& (.2) ct�11,�r. Acoll'a"Aid a a-(8) CD 40 Qseck:� Nag. Amia 2JA 'eff—a-k� j Pair e ins 2 -ra4wv 69 V�k 3 4 5�-J—.5 I 4&CA C4— &r Ct fc-1 6-3 --b N4 Ot . , 56e, fo i5A k,w Z ,- e-6- (2) bol 30 Z 6-L 2 f t � oq- s � o Q�•+r lQ pry v�.�-�- 8 31q Chemical Product inventory Form Building Occupant . � Building Address . City, State, Zip Code Field [nvestigator Date ! /f-1U Field Instrument Used aZ- Product Des.criptiion (commercial name, Volatile Ingredients In the dispenser type,container Cuanti Product size, manufacturer, tc. k C� o And AJV a6r 0 / go 6r�,- p, 2� a — 2 Y r C2 s � G 39-0-4,- , ce i is . � F -was ►r e�nr - D 304 Dv-li C&A-vver RM U wike-41- r n [ a1� Dq 3� �jlsseffyvd U C�� �- SOL- do , � F ave 5/� Chemical Product Inventory Form Building Cccupant_JCd7`ll 4&6,,, , aM Building Address 5&5 /.5��Aive City, State, Zip Code Field Investigator Cc, ,S' . f �.� Bate Field Instrument UsedT,�- �— Product Description (commercial name, Volatile Ingredients in the dispenser type, container Quantity Product size, manufacturer,etc. p lz P beer r tJ 2 az ' S P S f r. rI Z.f3z M 1 'OV9 1AW) 12, �z C 5 ►�'Tcxf c�2 el �+:,V\ 14 Ace 5 0" \Jwhx� �at dw 0,� k;f �Ovv,� -6 o4 U.1 Oz A P,t4"4 Wwcs -T"C4 A 6,44er N(k5kl (0,� �Z MTS c, Z3 01. 16.1 125 104 usLr cco", F,tf "f;�C CA6-4ri f 6u 0,_A f q dZ- ! cal 0) °z 0,4 OZ 20 zer 3Rz o� p6sl)� to b�. 1 G � -1k c .15 ' /8 re�icNR Sfi ^( 'F�.n�� 4-a6 6-,;L 11 INA 39. E 3vi Ar Carr f Ll i : e i I I : t Till 1 rij 1 ITI 00, JA . v f Tl 1 7 TI 1z, 1 H 1 S. Q i --1-- IQOman an : : ; t : i f r ' i : : : I � I ..:....... - I � RESIDENTIAL/COMMERCIAL/RETAIL QUESTIONNAIRE INDOOR AIR ASSESSMENT SURVEY This form must be completed for each building involved in an indoor air investigation. Preparers name i':T jf. �ti 4.� t.`�' Date prepared !" Preparer's affiliation �- /` rs" L' ' a�� .i Telephone number 2-. 01 OCCUPANT: Name J,ii u-, ltN+�� dle,.,N Address 501 d ''A s ll f City 64)WPI.A 1q , Telephone number W)Lo — 5N What is the best time to call to speak with you? Are you the [Owner, ❑Renter, ❑Other of this Structure? Total number of occupants/persons at this location? Average daily occupant/visitor population: 2 persons. Number of children?_ Ages? How long have you occupied this location? OWNER OR LANDLORD: Name (If different from occupant) Address Telephone number Land Use and Building Construction t Type (Check appropriate responses): Stesidential ❑Commercial ❑Office ElWarehouse FIStrip Mall 2. Age of the building?.... IqZ years. 3. Number of floors (stories) 4. Area of the building (square feet) 1q W 5. Is the building insulated? Wes CINo 6. How well is the building sealed? 7. Number of elevators in the B. Condition of the elevator pits (sealed, open earth, etc.) 9. Above-ground structure construction materials (check all that apply): FS&bod Brick ❑Concrete ❑Cement block ❑Other 10. General description of building construction materials 11. Does the building have windows that can be opened? es e 11a. If YES, indicate number and type(s) of window(s): 11 b. If YES, describ the frequency and duration of window opening: 12. Does the building have doors? NYes ❑No 12a. If YES, indicate number and type(s) of door: 12b. If YES, describe frequency and duration of door opening: C) 13, Foundation Construction (check all that apply): ❑Concrete slab on grade ❑Fieldstone f]Concrete block ❑Elevated above ground/grade ❑Full Basement R.G' imee— ❑Other [NOTE: If the building does not have a basement,go to question 24.1 14. Basement? ❑Yes, gNo Crawl Space? 5Yes, ❑No 14a. If YES, under how much of the building floor space? !L.% 15. Is the basement❑finished, or❑unfinished? 16. If finished, how many rooms are in the basement? 16a. How many are used for more than 2 hours/day? 17. Composition of basement floor (check all that apply) ❑Concrete ❑Tile. ❑Carpeted ❑Dirt ❑Wood ❑Other(describe) ? 17a. If concrete, is the floor ❑Sealed ❑Unsealed ❑Painted ❑Cohered ❑Cracked ❑Other(please specify) 18. Are the basement/foundation walls ❑Poured concrete ❑Cement block ❑Stone ❑Wood ©13rick ❑Other ? 18. Are the basementifoundation walls ❑Sealed ❑Unsealed ❑Unknown 20. Does the basement have a moisture or water infiltration problem (check one only)? ❑Yes, frequently (3 or more times/yr) ❑Yes, occasionally (1-2 times/yr) ❑Yes, rarely (less than 1 timelyr) ❑No 21. Does the basement ever flood (check one only)? ❑Yes, frequently (3 or more times/yr) ❑Yes; cccasonally (1-2 times/yr) f,3Yes, rarely(less than 1 time/yr) 17No 22. Does the basement have any of the following? (check all that apply) ❑Floor cracks, ❑Wall cracks ❑Sump ❑Floor drain ❑Other hole/opening in floor (describe) (Identify all potential soil gas entry points and their size (e.g., cracks, voids, pipes, utility ports, sumps, drain holes, etc.), and any fluid accumulated. 23. Are any of the following used or stored in the basement(check all that apply) ❑Paint ❑Paint stripper/remover ❑Paint thinner ❑Metal degreaser/cleaner ❑Gasoline ❑Diesel fuel ❑Solvents ❑Glue ❑Laundry spot removers ❑Drain cleaners ❑Pesticides Water and Sewage 24. What is the source of drinking water for the building (check all that apply)? ublic water supply Bottled water ❑Private Water Well. If private well, please answer following: ❑Drilled Well ❑Driven Well ❑Dug Well ❑Other(Specify) Water Well Specifications (if applicable) Well Diameter Grouted or Ungrouted Well Depth Type of Storage Tank Depth to Bedrock Size of Storage Tank Feet of Casing Describe type(s) of Treatment ❑Other, please specify 23. Are there taste and/or odor problems with the water supply? ❑Yes, ❑No If YES, please describe How long has the taste and/or odor problem been present? 2.4. Is the water chlorinated, brominated, or ozonated? ❑yes, ❑no, ❑unknown 25. Does the building have a private well for purposes other than drinking? ❑Yes ❑ No If YES, please describe purpose of the well: 26. Does the building have a septic system? Yes No Not used ❑Unknown 27. How is sewage disposed? R ublic Sewer eptic ❑Tank ❑Leach Field ❑Other (Specify) 28. What is the distance from the water supply well to septic system (if applicable)? feet 29a. Are septic tank additives used? ❑Yes ❑No ❑Unknown. If so,what type? 29. Is there standing water outside the building (pond, ditch, swale)? ❑Yes ❑No Heating, Ventilation, and Air Conditioning 30. Heating system fuel or power supply? Check all that apply: [Natural Gas ❑Heating Oil [-]Kerosene ❑Solar ❑Electric ❑Wood ❑Coal ❑Other 30a. Heat conveyance system: Forced hot air Heat Pump ❑Forced hot water ❑Steam ❑Radiant floor heat ❑Wood stove ❑Coal furnace ❑Fireplace ❑Electric Baseboard ❑Unvented Kerosene Heater ❑Other 31. Where is the heating system located? 04AW C_e. - 32. Does the building have air conditioning? Yes ❑No 32a. If YES, please check the appropriate type(s) Central air conditioning Window air conditioning unit(s) ❑Other, please specify 33. Does the building have any of the following? Room fans 041 i4-L- Ceiling fans 2 ❑Attic fans 34. Is the building ventilated using the fan-only mode of the central HVAC system? ❑Yes R40 34a. If YES, What is the rated size of the fan? 35. Water Heater Type: KGas ❑Electric ❑Other nn 36. !Water heater location: (please describe) Potential Indoor Sources of Pollution 37. Has the building had termite or other pesticide treatment: Yes No ❑Unknown 37a. If YES, please specify type of pest for which treatment was applied 37b. Approximate date of service 37c. Location of treatment within subject building 38. Has the building been recently (within the last six months) painted or remodeled? t9Yes ❑No 38a. If YES, please specify what was done, where in the building, and when: 38. Has new carpeting been installed In the building within the last year? ❑Yes XNo 39a. If YES, when and where? 40. Is a dry cleaning service present in the building (check only one box)? ❑Yes, dry-cleaning performed on-site des, dry-cleaning sent off-site, drop-off only 0 41. Has the building ever had a fire? ❑Yes FKNo 42. Are there any cooking appliances in the building? OYes ❑No 42a. If YES, describe: 43. Are the cooking appliances vented by use of exhaust hoods? ®Yes 43a. Do the hoods vent to the outdoors? Oyes 0 44. Is there an automatic dishwasher? 5Yes ❑No 44a. If YES, is the dishwasher Commercial grade, or esidential grade? 45. Is smoking allowed in the building? ❑Yes �RNo 45a. If YES, approximate number of smokers and level of smoking activity: (number of smokers) Light(<five cigarettes per day) Moderate (?I five cigarettes per day) Heavy(one or more packs per day,>20 cigarettes per day) 46. Are air fresheners reaularly used in the huilding? `Yes 9 ri d i e/S Cam) No 47. Are any of the following activities performed in the building? ❑Heating EOoidering []Welding ❑Painting (brush or roller) ❑Painting (spray) ❑Wood or metal finishing ❑Other activity involving chemical usage? (Please describe): 48. Please identify building cleaning and maintenance practices: Dusting []Dry sweeping Vacuuming Polishing (furniture, etc) ashin or wing-feel` Carpet cleaning ❑Other General building use of consumer products (please circle appropriate): Assume: Never = never used, Hardly ever = less than once/month, Occasionally = about once/month, Regularly = about once/week, and Daily = approximately once/day. Product Frequency of Use in Building Product Nev or Rarely Occasionally_ Regularly_ Daily. Spray-on deodorants Aerosol deodorizers Insecticides Disinfectants Window cleaners Spray-on oven cleaners Nail olish or remover Hairsprays Solvents/De reasers Paint or paint remover yC- Miscellaneous (specify) 49. Other comments: Figures/Additional Information Plan View: Sketch each floor and if applicable, indicate air sampling locations, possible indoor air pollution sources, preferential pathways and field instrument readings. Potential Outdoor Sources of Pollution: Draw a diagram of the area surrounding the building being sampled. If applicable, provide information on the spill locations (if known), potential air contamination sources (industries, service stations, repair shops, retail shops, landfills, etc.), outdoor air sampling locations, and field instrument readings. Also, on the diagram, indicate compass direction, [orations of water wells, septic systems, and utility corridors if applicable, and a statement to help locate the site on a topographical map. Complete the attached Chemical Products Inventory Form Chemical Product Inventory Form Building Occupant A-AwdJ 4-1-k Building Address .162 b- .1- City, State, Zip Code Field Investigator (-'(.4 Da Field Instrument Used NA- Pr6ddct 1136ikri pt i ' olatille Ingredients (commercial N .............. ........... ..Aso tYPq'.:::f'.QnR Per, : : ... ... .. ... -0 C. : ::41z9,'manuiict rer: C3 V A7vf I&e.4ra'w" - 62" At" A)a605/ 02 06 KIX tlow� 6-Z 0-r4, 2-1 L4� Oblsv g' AD is &A IWIZA 1 30 /-�de&j ac Pfd�604�L hZ6UTA ri T rr V- fo-"Z., OVA (7pi OrAJ Z7'o-z- r�.z,11 Er.0 7 Y � Lvleol 1,et�v pA041Via,I �j�ad�t• S�Ora`� �1 �G�.a.trt• ��.oi.r�CC � 5 ©L. G-ra� s�i�,•.�n� �4y�i r`b ks/h fit z 2 Wt }4! C la" 6Z frc' . cower a IL . ........... 72.- ....... 17-1 m .......... RESIDENTIALICOMMERCIALIRETAIL QUESTIONNAIRE INDOOR AIR ASSESSMENT SURVEY This form must be completed for each building involved in an indoor air investigation. Preparer's name A (7rA-ir-e4114U� )04a 7 Date prepared Preparer's affiliation ATC. Telephone number 0(„ —1033 OCCUPANT: Name.,_�V1( ���v��N�c=� Address_l �Cv Ave.. city � MIT Telephone number YQ10- 537 - 733 What is the best time to call to speak with you? Are you the Nowner, []Renter, ❑Other of this Structure? Total number of occupants/persons at this location? I Average daily occupant/visltor population: persons. Number of children? Ages? How long have you occupied this location? OWNER OR LANDLORD: dame (If different from occupant) Address Telephone number Land Use and wilding Construction 1. Type (Check appropriate responses): Residential Commercial ❑Office ❑Warehouse ❑Strip Mall 2. Age of the building? _ I years. Y91 3. Number of floors (stories) 4. Area of the building (square feet)_ IOW S. Is the building insulated? 9Yes ❑No 6. How well is the building sealed? 7. Number of elevators in the building 8. Condition of the elevator pits (sealed, open earth, etc.) 9. Above-ground structure construction materials (check all that apply): Wood Brick ❑Concrete ❑Cement block ❑Other 10. General description of building construction materials 11. Does the building have windows that can be opened? es No 11 a. If YES, indicate number and type(s) of window(s): 3` ee- 11b. If YES, describe the frequency and duration of window opening: 12. Does the building have doors? Eyes ❑No 12a. if YES, indicate numb r and type(s) of door: 12b. If YES, describe frequency and duration of door opening: 13. Foundation Construction (check all that apply): Concrete slab on grade ❑Fieldstone ❑Concrete block ❑Elevated above ground/grade ❑Full Basement ❑Crawispace ❑Other [NOTE: If the building does not have a basement, go to question 24.] 14. Basement? ❑Yes, ORNo Crawl Space? ❑Yes, NKIQ 14a. If YES, under how much of the building floor space? % 15. Is the basement❑flnished, or❑unfinished? 16. If finished, how many rooms are in the basement? 16a. How many are used for more than 2 hours/day? 17. Composition of basement floor(check all that apply) [Concrete.. � " . ❑Tile ❑Carpeted ❑Dirt ❑Wood ❑Other(describe) ? 17a. If concrete, is the floor ❑Sealed ❑Unsealed ❑Painted ❑Covered ❑Cracked ❑Other(please specify) 18. Are the basement/foundation walls .N'oured concrete ❑Cement block ❑Stone ❑Wood ❑Brick ❑Other ? 19. Are the basementifoundation walls ❑Sealed gUnsealed ❑Unknown 20. Does the basement have a moisture or water infiltration problem (check one only)? ❑Yes, frequently (3 or more times/yr) ❑Yes, occasionally (1-2 times/yr) ❑Yes, rarely (less than 1 time/yr) ❑No 21. Does the basement ever flood (check one only)? ❑Yes, frequently (3 or more times/yr) ❑Yes, occasionally (1-2 times/yr) ❑Yes, rarely (less than 1 time/yr) ❑No 22. Does the basement have any of the following? (check all that apply) ❑Floor cracks, ❑Wall cracks ❑Sump ❑Floor drain ❑Other hole/opening in floor (describe) (Identify all potential soil gas entry points and their size (e.g., cracks, voids, pipes, utility ports, sumps, drain holes, etc.), and any fluid accumulated. 23. Are any of the following used or stored in the basement(check all that apply) airt v N[Paint stripper/remover 7 NiPaint thinner ? &Metal degreaser/cleaner-A� rw%v%COk &Gasoline []Diesel fuel ®Solvents ? Glue Laundry spot removers ❑Drain cleaners ❑Pesticides Water and Sewage 24. What is the source of drinking water for the building (check all that apply)? ublic water supply Bottled water []Private Water Well. If private well, please answer following: ❑Dniled Well ❑Driven Well ❑Dug Well ❑Other (Specify) Wate,Well Specifications (if applicable) Well Diameter Grouted or Ungrouted Neil Depth Type of Storage Tans Depth to Bedrock Size of Storage Tank Feet of Casing Describe type(s) of Treatment ❑Other, please specify 23. Are there taste and/or odor problems with the water supply? ❑Yes N o If YES, please describe How long has the taste and/or odor problem been present? 24. Is the water chlorinated, brominated, or ozonated? ❑yes, Ono, ❑unknown 25. Does the building have a private well for purposes other than drinking? ❑Yes 'RNo If YES, please describe purpose of the well: 26. Does the building have a septic system? ❑Yes ®No ❑Not used ❑Unknown 27. How is sewage disposed? ,Public Sewer ❑Septic ❑Tank ❑Leach Field ❑Other (Specify) 28. What is the distance from the water supply well to septic system (if applicable)? feet 29a. Are septic tank additives used? ❑Yes ❑No ❑Unknown. if so, what type? 29. Is there standing water outside the building (pond, ditch, swale)? ❑Yes ❑No Heating, Ventilation, and Air Conditioning 30. Heating system fuel or power supply? Check all that apply, ❑Natural Gas ❑Heating Oil ❑Kerosene ❑Solar ERF-lectric +Wood ❑Coal ❑Other 30a. Heat conveyance system: []Forced hot air ❑Meat Pump [-]Forced hot water ❑Steam ❑Radiant floor heat ❑Wood stove ❑Coal furnace Flreplacs .KElectric Baseboard Unvented Kerosene Heater [JOther 31. Where is the heating system located? LJ ,rkYr.,. 32. Does the building have air conditioning? Oyes PNo 32a. If YES, please check the appropriate type(s) HCentral air conditioning IMindow air conditioning unit(s) ❑Other, please specify 33. Does the building have any of the following? KR,oom fans ❑Ceiling fans ❑Attic fans 34. is the building ventilated using the fan-only mode of the central HVAC system? ❑Yes ❑No 34a. If YES, What is the rated size of the fan? 35. Water Heater Type: Gas Electric ❑Other 36. Water heater location: (please describe) G Potential Indoor Sources of Pollution 37. Has the building had termite or other pesticide treatment: FYes 0 Unknown 37a. If YES, please specify type of pest for which treatment was applied 37b. Approximate date of service 37c. Location of treatment within subject building 38. Has the building been recently (within the last six months) painted or remodeled? W Yes o 38a. If YES, please specify what was done, where in the building, and when: 39. Has new carpeting been installed in the building within the last year? Yes No 39a. If YES, when and where? 40. Is a dry cleaning service present in the building (check only one box)? OYes, dry-cleaning performed on-site RYes, dry-cleaning sent off-site, drop-off only No 41. Has the building ever had a fire? Yes No 42. Are there any cooking appliances in the building? ®Yes ❑No 42a. If YES, describe: 43. Are the cooking appliances vented by use of exhaust hoods? Rues ❑ No 43a. Do the hoods vent to the outdoors? ❑Yes Flo 44. Is there an automatic dishwasher? 9'�es ❑No 44a. If YES, is the dishwasher ❑ ommercial grade, or esidential grade? 45. Is smoking allowed in the building? ❑Yes f KNo 45a. If YES, approximate number of smokers and level of smoking activity: (number of smokers) Light (<five cigarettes per day) Moderate (>five cigarettes per day) Heavy (one or more packs per day,>20 cigarettes per day) 46. Are air fresheners regularly used in the building? es No 4T Are any of the following activities performed in the building? []Heating []Soldering ❑Welding ❑Painting (brush or roller) ❑Painting (spray) ❑Wood or metal finishing ❑Other activity involving chemical usage?(Please describe): 48. Please identify building cleaning and maintenance practices: usting Dry sweeping NVacuuming CKPolishing (furniture, etc)—A)cyf o � JNWashing or we laors— ❑Carpet cleaning ❑Other General building use of consumer products (please circle appropriate): Assume: Never = never used, Hardly ever = less than once/month, Occasionally = about oncelmonth, Regularly = about once/week, and Daily = approximately once/day. Product Frequency of Use in Building Product Never Rarely Occasionally Regularly Dail Spray-on deodorants Aerosol deodorizers Insecticides Disinfectants Window cleaners Spray-on oven cleaners Nail polish or remover IK Flair sprays Solve nts/Deg reasers Paint or paint remover Miscellaneous (specify) 49. Other comments: Figures/Additional Information Plan View: Sketch each floor and if applicable, indicate air sampling locations, possible indoor air pollution sources, preferential pathways and field instrument readings. Potential Outdoor Sources of Pollution: Draw a diagram of the area surrounding the building being sampled. If applicable, provide information on the spill locations (if known), potential air contamination sources (industries, service stations, repair shops, retail shops, landfills, etc.), outdoor air sampling locations, and field instrument readings. Also, on the diagram, indicate compass direction, locations of water wells, septic systems, and utility corridors if applicable, and a statement to help locate the site on a topographical map. Complete the attached Chemical Products Inventory Form ChemicaE Product Inventory Form Building Occupant Aad 9!�2n� Building Address '363 11,"1" Ave-0 City, State, Zip Code 13ef?eA-lia4-7 wj :r Field Investigator CGk&!q Date C) Field Instrument Used AIA— P ..... . . .. ........... .. ........... . . . ...... : :Volatile latile Ingredien . . is In the . ...... .............. twiner ............ 'manu -is ze':" acturer Jatc. ": tr IT T,C.- ZA 0- V-t,,-:--T- AIA14 4t gq 5,6 tQ TitdL_ A;t #64tAd L11 "1 -24 W&JI dk_ V's orz- �p A PM .N d Oha�A L44.Lo-, I-re, 190w 6"x'r Wye Wl Ti-Po" OLeve Pro Li�� '►� �� C,,Q,�-e �� 0/0 Air LIO . pis SX,b ev Pia f r.•r/ t �r �� p (s rv� /* d-I Y�2) ,ern 5 rgio- -� Asa fire) Aleo`i,o l (i-V5 A 0 Aim �, kr 'Z &L l i : I I I : I l �: � � t . - � _ , 1 _.. �� i ....�. ...� .: —.t ... ; .. .. .. .. I . "' I` ���� .. ....... t c .. ': i �' t I �. �. i i [ .., i ... �, f . . ! .; � .. ; - . ... _ .. �: _. �� : . _ � .. . :. .. i.r .: � w � . � � � j 1 -. � . �' •I =� � - � - . . i ... . ; .. ....:...... _. ... . �� � � i �� � ��� .� � � �. . ��� _.� � , .. . . . . i � � .. i .. t i � .. I 1 i e e � i �, j � E ........... ... ... ................,. .........._ i i i i .. i i i ? : i i f I� i i RESIDENTIAUCOMMERCIALIRETAIL QUESTIONNAIRE IKDOOR AIR ASSESSMENT SURREY This form must be completed for each building involved in an indoor air Investigation. Preparer's name CL +fc51l �� " Date prepared 1 2_ -,16 Preparer's affiliation A7- Telephone number q0(o--M3-7/033 OCCUPANT: Name C, AfV Address �3 f�� Aye- City 319-Z-4'Aajn Telephone number r3 -�A¢30 v What is the best time to call to speak with you? Are you the ❑Owner, CKRenter, ❑Other of this Structure? Total number of occupants/persons at this location? � Average daily occupanttv3Zr population: persons. Number of children? _Ages? How long have you occupied this location? OWNER OR LANDLORD: Name moy'�'Gi �(p� ve, UIC (If different from occupant) Address Telephone number Land Use and Building Construction 1. Type (Check appropriate responses): ❑Residential Commercial ❑Office ❑Warehouse ❑Strip Mall 2. Age of the building? years. 3. Number of floors (stories) 4. Area of the building (square feet) , 5. Is the building insulated? 99�yes ❑No 6. How well is the building sealed? 7. Number of elevators in the building /VJ 8. Condition of the elevator pits (sealed, open earth, etc.) 9. Above-ground structure construction materials (check all that apply): Wood ❑Brick ❑Concrete ❑Cement block ❑Other 10. General description of building construction materials 11. Does the building have windows that can be opened? Oyes ❑No 11 an 1f YES, indicate number lind type(s) of window(s): 11 b. If YES, describe the frequency and duration of window opening: R 12. Does the building have doors? We$ ❑No 12a. If YES, in icate number and type(s) of door: r 12b. If YES, deocribeffrequency and duration of door opening: 13. Foundation Construction (check all that apply): Woncrete slab on grade ❑Fieldstone ❑Concrete block ❑Elevated above ground/grade RFull Basement Crawlspace ❑Other (NOTE: If the building does not have a basement, go to question 24.1 14. Basement?❑Yes, Vo Crawl Space?( es, ❑No 14a. If YES, under how much of the building floor space? % 15. Is the basement[]finished, or❑unfinished? 16. If finished, how many rooms are in the basement? 16a. How many are used for more than 2 hours/day? 17. Composition of basement floor(check all that apply) ❑Concrete ❑Tile []carpeted ❑Dirt ❑Wood ❑Other(describe) ? 17a. If concrete, is the floor ❑Sealed ❑Unsealed ❑Painted ❑Covered ❑Cracked ❑Other(please specify} 18. Are the basement/foundation walls Woured concrete ❑Cement block ❑Stone ❑Wood ❑Brick ❑Other ? 19. Are the basement/foundation walls ❑Sealed [Unsealed nknown 20. Does the basement have a moisture or water infiltration problem (check one only)? ❑Yes, frequently(3 or more times/yr) ❑Yes, occasionally (1-2 times/yr) []Yes, rarely (less than 1 time/yr) ❑No 21. Does the basement ever flood (check one only)? ❑Yes, frequently (3 or more times/yr) ❑Yes, occasionally (1-2 times/yr) ❑Yes, rarely (less than 1 time/yr) ❑No 22. Does the basement have any of the fallowing? (check all that apply) ❑Floor cracks, ❑Wall cracks ❑Sump ❑Floor drain ❑Other hole/opening in floor (describe) (Identify all potential soil gas entry points and their size (e.g., cracks, voids, pipes, utility ports, sumps, drain holes, etc.), and any fluid accumulated. 23. Are any of the following used or stored in the basement(check all that apply) ❑Paint ❑Paint stripper/remover ❑Paint thinner ❑Metal degreaser/cleaner ❑Gasoline ❑Diesel fuel ❑Solvents ❑Glue ❑Laundry spot removers ❑Drain cleaners ❑Pesticides Water and Sewage 24. What is the source of drinking water for the building (check all that apply)? Public water supply ❑Bottled water ❑Private Water Well. If private well, please answer following: ❑Drilled Well ❑Driven Well []Dug Well ❑Other(Specify) Water Well Specifications (If applicable) Well Diameter Grouted or Ungrouted Well Depth Type of Storage`rank Depth to Bedrock Size of Storage€ank Feet of Casing Describe type(s) of Treatment ❑Other, please specify 23. Are there taste and/or odor problems with the water supply? ❑Yes, ❑No If YES, please describe Flow long has the taste and/or odor problem been present? _ 24. Is the water chlorinated, brominated, or ozonated? ❑yes, []no, ❑unknown 25. Does the building have a private well for purposes other than drinking? ❑ Yes ❑ No If YES, please describe purpose of the well: 26. Does the building have a septic system? Yes 0 Not used ❑Unknown 27. How is sewage disposed? C�Oublic Sewer ❑Septic ❑Tank ❑t.each Field []Other(Specify) 28. What is the distance from the water supply well to septic system (if applicable)? feet 29a. Are septic tank additives used? []Yes ❑No ❑Unknown. If so, what type? 29. Is there standing water outside the building (pond, ditch, swale)? ❑ Yes ❑No Heating, Ventilation, and Air Conditioning 30. Heating system fuel or power supply? Check all that apply: atural Gas 'Heating Oil ❑Kerosene ❑Solar ❑Electric ❑Wood ❑Coal ❑Other 30a. Heat conveyance system: ❑Forced hot air ❑!feat Pump OForced hot water ❑Steam ❑Radiant floor heat ❑Wood stove ❑Coal furnace []Fireplace ❑Electric Baseboard ❑Unvented Kerosene Heater ❑Other r i 31. Where is the heating system located? L4,r �n iP�r2f ��GPf 32. Does the building have air conditioning? ❑yes No 32a. If YES, please check the appropriate type(s) ❑Central air conditioning ❑Window air conditioning unit(s) ❑Other, please specify 33. Does the building have any of the following? M 'om fans';`^^"`�� Ming fans Attic fans 34. Is the building ventilated using the fan-only mods of the central HVAC system? ❑Yes ❑No 34a. If YES,What is the rated size of the fan? 35. Water Heater Type: Gas Electric ❑Other 36. Water heater location: (please describe) AL4 S,--m — — Potential Indoor Sources of Pollution 37. Has the building had termite or other pesticide treatment: ❑Yes R Q unknown 37a. If YES, please specify type of pest for which treatment was applied 37b. Approximate date of service 37c. Location of treatment within subject building 38. Has the building been recently (within the last six months) painted or remodeled? ❑Yes [RNo )4c a 38a. If YES, please specify what was done,where in the building, and when: 39. Has new carpeting been installed in the building within the last year? ayes kSNo 39a. If YES, when and where? 40. Is a dry cleaning.service present in the building (check only one box)? ❑Yes, dry-cleaning performed on-site ❑Yes, dry-cleaning sent off-site, drop-off only &Io 41. Has the building ever had a fire? Yes No 42. Are there any cooking appliances in the building? Lies ❑No 42a. If YES, describe: 43. Are the cooking appliances vented by use of exhaust hoods? FYes .K No 43a. Do the hoods vent to the outdoors? E]Yes ❑NO 44. Is there an automatic dishwasher? . ,Yes ❑No 44a. if YES, Is the dishwasher '�Gommercial grade, or []Residential grade? 45. Is smoking allowed in the building? Yes 0 45a. If YES, approximate number of smokers and level of smoking activity: (number of smokers) Light (<five cigarettes per day) Moderate (>five cigarettes per day) Heavy (one or more packs per day, ?20 cigarettes per day) 46. Are air fresheners regularly used in the building? §Ves ❑No 47. Are any of the following activities performed in the building? ❑Heating ❑Soldering [-]Welding IgPainting (brush or roller) ❑Painting (spray) ❑Wood or metal finishing ❑Other activity involving chemical usage? (Please describe): 48. Please identify building cleaning and maintenance practices: Dusting ry sweeping acuuming Cj Polishing (fur ' re etc , !, Washing or axing floor N� []carpet cleaning ❑Other General building use of consumer products (please circle appropriate): Assume: Never = never used, Hardly ever = less than once/month, Occasionally = about once/month, Regularly = about once/week, and Daily = approximately oncefday. Product Frequency of Use in Building Product Ne er Rarely Occasionally_ Regularly Dail Spray-on deodorants Aerosol deodorizers Insecticides Disinfectants Window cleaners Spray-on oven cleaners Nall polish or remover fairsprays Solvents/Degreasers Paint or paint remover Miscellaneous (specify) 49. Other comments: Figures/Additional Information Plan View: Sketch each floor and if applicable, indicate air sampling locations, possible indoor air pollution sources, preferential pathways and field instrument readings. Potential Outdoor Sources of Pollution: Draw a diagram of the area surrounding the building being sampled. If applicable, provide information on the spill locations (if known), potential air contamination sources (industries, service stations, repair shops, retail shops, landfills, etc.), outdoor air sampling locations, and field instrument readings. Also, on the diagram, indicate compass direction, locations of water wells, septic systems, and utility corridors if applicable, and a statement to help locate the site on a topographical map. Complete the attached Chemical Products Inventory Form Chemical Product Inventory Form Building Occupant -46C Building AddressA*,P— City, State, Zlp Code Field Investigator C,A /04 'Date 1- 12 - /a Field Instrument Used 11J.4 Ct Motici" ..........! lngredlent.s...!� .. .... . . ct manufa' :.::::size Am N L"kw byzA ka 4-oAdL J, Wt3 &IJ 0 tyr A-tfi -1 5 01 0� W7TlM r T. ,- 44-0/& SM)-CeYi I �kj r"rllc pa�nk"ecu V 6-?,-/ ZOR: I 41 cx 402- —Up) - Dt,lowvsQl-rim !� O-S — (2--) Uwi r6 300 0�Ct2_ /jP 10 2- (Z. F,W-A. Go-To (L207- - W +-C�) fox Di:5 44- 3,5 4.., 60,f M�,Y #", tow b -Sh�ve c4x_.�-m,. Ac,r A-ild- rf-�- rt 16 C t04 Ro 6.1 fro s Sol 13°� tb-P GtI-e,4�'I(Q,r Il off- kJ -a 2rw� 14" )!o 0�- 1'ui n Pdt �ia.e M 32Lj4fi te- az: � �� calms z,�S� Pot C.0+ cis )o dd 3.2 e.:x- C S U 222. Cw G� r 2- 1 A� C"e &4k Xa ,r �s Ara- 76 Chemical Product Inventory Form Building Occupant A-L- ;)a ca4r- Building Address 2214 610, City, State, Zip Code Field Investigator C, LU Field Instrument Used duc .......... "6&":irqiai pa me ..-Volati.119.1ingredionts In the.'.";"-v- P 1.(Wuct size; 13 C'Y':- ' manufactuirer,' t . ...... bold& 6-Z- 3-' 541-Am.,i45 ba All, ct rim de Mwp"d;I A C1 6V Faces Or- 0; iq� 'S�Ch SP - c9 L Rmx�I S+V-f Qn-r 33 -S d7-- Icy (:23 Dote- Ad 0 q0 � �- q0 ot — 09,, kr 41) I C ayk4if" 313 }: :S7 ct '. 4..: .. .1cJ 0 A. �» � c6 0 cts i A RESIDENTIALICOIMdIMERCIALIRETAIL QUESTIONNAIRE INDOOR AIR ASSESSMENT SURVEY This form must be completed for each building involved in an indoor air investigation. Preparer's name UeSMY4ur/LAAA v,kkgr-Avyi Date prepared I-l i-i0 Preparer's affiliation... Telephone number OCCUPANT: Name Alov w&n + Vjeiirl.t'a 0,s0h Address 4b Z N I t�`'`` Ave. city r axa n Telephone number 106 - q51 - 15s y (1 kenlcan d(l) What is the best time to call to speak with you? Are you the J%Owner, ❑Renter, [-]Other of this Structure? Total number of occupants/persons at this location? 9 Average daily occupant/visitor population: persons. Number of children? Allf _Ages? How long have you occupied this location? OWNER OR LANDLORD: fume w 5lr-e— (If different from occupant) Address Telephone number Land Use and Building Construction 1. Type (Check appropriate responses): Residential Commercial []Office ❑Warehouse ❑Strip Mall 2. Age of the building? q1 years. 3. Number of floors (stories) 1 4. Area of the building (square feet) Z�S `n LO` loo-Ic-5 5. is the building insulated? MYes ❑No 6. How well is the building sealed? I 7. Number of elevators in the building VA 8. Condition of the elevator pits (sealed, open earth, etc.) �- 9. Above-ground structure construction materials (check all that apply): ®Wood ❑Brick ❑Concrete ❑Cement block ❑Other 10. General description of building construction materials Imi 11. Does the building have windows that can be opened? es No 11 a. If YES, indicate nurqPer and type(s) of window(s): 11 b. If YE , describe the frequency and duration of window opening: 12. Does the building have doors? Yes No 12a. If YES, Indicate number and type(s) of door: 12b. If YES, describe fre u ncy and duration of door opening: 13. Foundation Construction (check all that apply): ❑Concrete slab on grade ❑Fieldstone ❑Concrete block ❑Elevated above ground/grade gFull Basement ❑Crawispace ❑Other [NOTE: If the building does not have a basement, go to question 24.] 14. Basement?XYes, ❑No Crawl Space? ❑Yes,`ONo 14a. If YES, under how much of the building floor space? % 16. Is the basement Wnished, or❑unfinished? 16. If finished, how many roams are in the basement? 16a. plow many are used for more than 2 hours/day? fi4k. 17. Composition of basement floor(check all that apply) Concrete Tile Carpeted/,nn040-�-" Dirt ❑Wood ❑Other(describe) 17a. If concrete, is the floor []Sealed nAu-1Y` ❑Unsealed ❑Painted ❑Covered ❑Cracked ❑Other(please specify) 18. Are the basement/foundation walls oured concrete Cement block ❑Stone ❑Wood ❑Brick [-]Other ? 19. Are the basement/foundation walls ❑Sealed F,H iJuj ❑Unsealed ❑Unknown 20. Does the basement have a moisture or water infiltration problem (check one only)? ❑Yes, frequently (3 or more times/yr) []Yes, occasionally (1-2 timeslyr) ❑Yes, rarely(less than 1 time/yr) [ dNo 21. Does the basement ever flood (check one only)? ❑Yes, frequently (3 or more timeslyr) ❑Yes, occasionally (1-2 timeslyr) Yes, rarely (less than 1 time/yr) RNO 22. Does the basement have any of the following? (check all that apply) ❑Floor cracks, ❑Wall cracks ❑Sum;" Floor drain �ru,-,Z� ,Q�P,,, Other hole/opening in floor (describe) (Identify all potential soil gas entry points and their size (e.g., cracks, voids, pipes, utility ports, sumps, drain holes, etc.), and any fluid accumulated. 23. Are any of the following used or stored in the basement (check all that apply) aint Paint stripper/remover ❑Paint thinner ❑Metal degreaser/cleaner [-]Gasoline ❑Diesel fuel ❑Solvents ❑Glue ❑Laundry spot removers ❑Drain cleaners ❑Pesticides Water and Sewage 24. What is the source of drinking water for the building (check all that apply)? Oublic water supply [:]Bottled water ❑Private Water Well. If private well, please answer following: ❑Drilled Well ❑Driven Well ❑Dug Wail ❑Other(Specify) Water Well Specifications (if applicable) Weld Diameter Grouted or Dngrouted 'NeE,: Depth Type of Storage Tank Depth to Bedrock Size of Storage Tank Feet of Casing Describe type(s) of Treatment ❑Other, please specify 23. Are there taste and/or-odor problems with the water supply? []Yes, [-]No If YES, please describe How long has the taste and/or odor problem been present? 24. Is the water chlorinated, brominated, or ozonated? []yes, ❑no, ❑unknown 25. Does the building have a private well for purposes other than drinking? ❑Yes &INo If YES, please describe purpose of the well: 26. Does the building have a septic system? ❑Yes ❑No ❑Not used ❑Unknown 27. How is sewage disposed? Public Sewer Septic ❑Tank ❑Leach Field ❑Other(Specify) 28. What is the distance from the water supply well to septic system (if applicable)? feet 29a. Are septic tank additives used? ❑Yes [:]No ❑Unknown. If so,what type? 29. Is there standing water outside the building (pond, ditch, swale)? Yes No Heating, Ventilation, and Air Conditioning 30. Heating system fuel or power supply? Check all that apply: BINatural Gas ❑Heating Oil ❑Kerosene ❑Solar ❑Electric ❑Wood ❑Coal ❑Other 30a. Heat conveyance system: []Forced hot air ❑Heat Pump Forced hot water Steam ❑Radiant floor heat ❑Wood stove ❑Coal furnace Fireplace Electric Baseboard ❑Unvented Kerosene Heater ❑Other 31. Where is the heating system located? S 32. Does the building have air conditioning? Yes No 32a. If YES, please check the appropriate type(s) ❑Central air conditioning Window air conditioning unit(s) ❑Other, please specify 33. Does the building have any of the following? - JJO ❑Room fans ❑Ceiling fans ❑Attic fans 34. Is the building ventilated using the fan-only mode of the central HVAC system? ❑Yes Arlo P 34a. If YES, What is the rated size of the fan? 35. Water Heater Type: &'Ga Elesctric ❑Other 36. Water heater location: (please describe) '« Potential Indoor Sources of Pollution 37. Has the building had termite or other pesticide treatment: ❑Yes 0 Unknown 37a. If YES, please specify type of pest for which treatment was applied 37b. Approximate date of service 37c. Location of treatment within subject building 38. Has the building been recently (within the last six months) painted or remodeled? Yes No 38a. If YES, please specify wha wa done, wh re in the building, an when: YvItth 39. Has new carpeting been installed in the building within the last year? ❑Yes PNo 39a. If YES, when and where? 40. Is a dry cleaning service present in the building (check only one box)? ❑Yes, dry-cleaning performed on-site �Yes, dry-cleaning sent off-site, drop-off only No 41. Has the building ever had a fire? ❑Yes FINo 42. Are there any cooking appliances in the building? es No 42a�5, describe: 43. Are the cooking appliances vented by use of exhaust hoods? t5yes ❑ No 43a. ®o the hoods vent to the outdoors? ❑Yes KNo 44. Is there an automatic dishwasher? es No 44a. If YES, is the dishwasher R ommercial grade, or esidential grade? 45. s smoking allowed in the building? ,des ❑No 45a. If YES, approximate number of smokers and level of smoking activity: �� (number of smokers) V I.lght (<five cigarettes per day) Moderate (L>five cigarettes per day) Heavy(one or more packs per day, >20 cigarettes per day) 46. Are air fresheners regularly used in the building? MYes ❑No 47. Are any of the following activities performed In the building? - ❑Heating []Soldering []Welding ❑Painting (brush or roller) ❑Painting (spray) ❑Wood or metal finishing []Other activity involving chemical usage? (Please describe): 48. Please identify building cleaning and maintenance practices: Dusting Dry sweeping Vacuuming olishing (furniture, etc) twco; ashing or waxing floors arpet cleaning her General building use of consumer products (please circle appropriate): Assume: Never = never used, Hardly ever = less than once/month, Occasionally = about oncehnonth, Regularly = about oncetweek, and Daily = approximately once/day. Product Frequency of Use in Building Product Never Rarely Occaslonall Re ularl Dail Spray-on deodorants Aerosol deodorizers Insecticides Disinfectants Wndow cleaners Spray-on oven cleaners Nail poilsh or remover Hair s ra s Solvents/Degreasers Paint or paint remover Miscellaneous (specify) -" 49. Other comments: Figures/Additional Information Plan View: Sketch each floor and if applicable, indicate air sampling locations, possible indoor air pollution sources, preferential pathways and field instrument readings. Potential Outdoor Sources of Pollution: Draw a diagram of the area surrounding the building being sampled. if applicable, provide information on the spill locations (if known), potential air contamination sources (industries, service stations, repair shops, retail shops, landfills, etc.), outdoor air sampling locations, and field instrument readings. Also, on the diagram, indicate compass direction, locations of water wells, septic systems, and utility corridors if applicable, and a statement to help locate the site on a topographical map. Complete the attached Chemical Products Inventory Form Chemical Product Inventory Form Building Occupant wpm 4 K40a. N'509" Building Address q1)9 ! 1n ye- City, State, Zip Code Field Investigator& Date -0/0 Field Instrument Used Pro ercial name, :-�.-`.-::--VoIatIIe IngroOlents in P ro uct.:'*- etc.) 0 -IV F An"LOA, 13� tlizjsE r 2,62, — CA bu-, IIM 3,`72-L - L:Z� i&A ,vicAze-2;4 k"14 X9 Chemical Product ,Inventory Form A Building Occupant rm` l— Alu Building Address L/h 2 &A40A - City, State, Zip Code /K Field Investigator I ktoja4m,Date I-- Field Instrument Used D c to uct es .....:....::::..:... ::.....:::::...:....... . :.....:.. :....::;.::::::.::;.:::.;:: .. :::.:::Volatile,ingredients.in.the.�:::� m8.. ... _............. ,.....:.......... tI Product 'contallne dispe�ts�ar:tY.pe►.::..::::.:.: :..:::::•::�`:.::.,,:::�....:..:,...................::. manufacturera c: :::: ::::: .::. ::.:::.:::.::.:::::::,:::::::::::::.::.:... ...::,........:.:.:::...:.•:.::.:::,.:.:..::.........:..-....... ............:.:. A fwr ty 3o'l o powl ZI a - 2 21. z W �. r -� :f" oBi 3a CEO 9 -++ cc) f IA?I fJt al ( U ' �3 d (2) X _ ateyc g17 3 22 eF-t. -VY/11�C4 +Lf lCod �,lv Fi�ov- ta,%Mo,� 13" T-41� ca4,-4- y;hz cold sr;cz, V a . f W - a 03 , *j 6? pj= 5� l � 05ca PI 1 A 3D 1 L f4At"— fo � a * WVOW Cyr 11?)-ad�- 1 -�- 1i vffli� -bo grL Cha)XL- irk • (,��, 5ilE con —C 3/ Chemical Product Inventory Form Building Occupant mm4u - , d-S, Building Address City, State, Zip Code zhX Field Investigator C Date !7� Field Instrument Use :Pro uct.IDO d116n .1 th • ts if 0 ... ....... .......... Quantity::­ dls .1 6ontain6f." .1. . ... L Y size r .--.e q:or t .................. .. . 16, 32-q V�:� wm,I Y1.0 A hSA _Ad�611 N Aj_ AOS 6177 4F cl 43 Atw r it 4 P-Sas 3 AV; INY- 4o 12 1 -lid dw , PK) 32- Un _w die Ve&/?� 1* /1'.s- q. �- '° P � MCI -2cr �� Dry i2 ��� � a Le her y Moycr -T�,,,► — TV raw P S6Aw 3,� 6-:z7 - (2,� P � A �' � A Simi bza Qo�o 3a -�f+ e,-Y- ko 6Z, �24 0 Valve fig BOW-96 oil � - ` bI a �a 0; 30 krb Chemical Product Inventory Form Building Occupant .I/- ,,In /E�Rrt-;A- Building Address A/ 1Y.4 City, State, Zip C,4ode - MT, Date I- Field Investigator CG 11- - Field Instrument Used on Nidriptl lati-le.Ing.redients In the:: , cor>ramerctal..name,:..;.::.::::: Quantl . .... anu 2ct!AC ikA eld el r— L &MW"e;, : : ...... ref ' � � ... .. : : 46 ar Ix ON ! 303% :. ... .: ....•......... ....................... : I ; I : : rr i : 6 I[ '� 4S i : e RESIDENTIALICOMMERCIALIRETAIL QUESTIONNAIRE INDOOR AIR ASSESSMENT SURVEY This form must be completed for each building involved in an indoor air investigation. Preparers name 6 �,7 �1,�,� � Date prepared Preparer's affiliation 26-1-M Telephone number OCCUPANT: Name Address Llty Telephone number What is the best time to call to speak with you? Are you the ❑Owner,0enter, ❑Other of this Structure? Total number of occupants/persons at this location? Average daily occupanttvisitor population: persons. Number of children?---- Ages? -r How long have you occupied this location? OWNER OR LANDLORD: Name 1-ho as 4pe Scl—tl-f,LO (If different from occupant) Address. 3)alrm W dO - Telephone number qt)�- L(933 W-+ 96sso Land Use and Building Construction 1. Type (Check appropriate responses): Residential ommercial Office ❑Warehouse ❑Strip Mall 2. Age of the building? years. 3. Number of floors (stories) f 4. Area of the building (square feet) 6. Is the building insulated? EgYes ❑No 6. How well is the building sealed? +L 7. Number of elevators in the building a. Condition of the elevator pits (sealed, open earth, etc,) 9. Above-ground structure construction materials (check all that apply): ❑Wood ❑Brick ❑Concrete ❑Cement block ❑Other 10. General description of building construction materials 11. Does the building have windows that can be opened? 2fes ❑No 11 a. If YES, indicate number and type(s) of window(s): 11b. If YES, describe the frequency and duration of window opening: 12. Does the building have doors? {files ❑No 12a. If YES, indicate number and type(s) of door: 12b. If YES, describe frequency and duration of door opening: 13. Foundation Construction (check all that apply): ❑Concrete slab on grade ❑Fieldstone ❑Concrete block ❑Elevated above ground/grade ❑Full Basement ❑Crawlspace ❑Ether [NOTE: If the building does not have a basement, go to question 24.1 14. Basement? ❑Yes, ❑No Crawl Space? ❑Yes, ❑No 14a. If YES, under how much of the building floor space? % 15. Is the basement❑finished, or❑unfinished? 16. If finished, how many rooms are in the basement? 16a. How many are used for more than 2 hours/day? 17. Composition of basement floor(check all that apply) ❑Concrete ❑Tile ❑Carpeted ❑Dirt ❑Wood ❑Other (describe) ? 17a. If concrete, is the floor ❑Sealed ❑Unsealed ❑Painted ❑Covered ❑Cracked ❑Other(please specify) 18. Are the basement/foundation walls ❑Poured concrete ❑Cement block ❑Stone ❑Wood ❑Brick ❑Other ? 19. Are the basement/foundation walls ❑Sealed ❑Unsealed ❑Unknown 20. Does the basement have a moisture or water infiltration problem (check one only)? ❑Yes, frequently (3 or more times/yr) ❑Yes, occasionally (1-2 times/yr) ❑Yes, rarely (less than 1 timetyr) ❑No 21. Does the basement ever flood (check one only)? ❑Yes, frequently (3 or more times/yr) ❑Yes, occasionally (1-2 times/yr) ❑Yes, rarely (less than 1 time/yr) ❑No 22. Does the basement have any of the following? (check all that apply) ❑Floor cracks, ❑Wail cracks []sump ❑Floor drain E110ther hole/opening in floor (describe) (Identify all potential soil gas entry points and their size (e.g., cracks, voids, pipes, utility ports,sumps, drain holes, etc.), and any fluid accumulated. 23. Are any of the following used or stored in the basement(check all that apply) ❑Paint []Paint stripper/remover ❑Paint thinner ❑Metal degreaser/cleaner ❑Gasoline ❑Diesel fuel ❑Solvents ❑Glue ©Laundry spot removers ❑Drain cleaners ❑Pesticides Water and Sewage 24. What is the source of drinking water for the building (check all that apply)? ❑Public water supply ❑Bottled water ❑Private Water Well. if private well, please answer following: HDrilled Well Driven Well ❑Dug Well ❑Cther(Specify) Water Well Specifications(if applicable) Well Diameter Grouted: or tingrouted Well Depth Type of Storage Tank Depth to Bedrock Size of Storage Tank Feet of Casing ^escribe type(s) of Treatment ❑Other, please specify 23. Are there taste and/or odor problems with the water supply? ❑Yes, ❑No If YES, please describe How long has the taste and/or odor problem been present? 24. Is the water chlorinated, brominated, or ozonated? ❑yes, ❑no, ❑unknown 25. Does the building have a private well for purposes other than drinking? ❑Yes ❑ No If YES, please describe purpose of the well: 26. Does the building have a septic system? ❑Yes ❑No ❑Not used ❑Unknown 27. How is sewage disposed? ❑Public Sewer ❑Septic ❑Tank ❑Leach Field ❑Other (Specify) 28. What is the distance from the water supply well to septic system (if applicable)? feet 29a. Are septic tank additives used? ❑Yes ❑No ❑Unknown. If so,what type? 29. Is there standing water outside the building (pond, ditch, swale)? ❑Yes ❑No Heating, Ventilation, and Air Conditioning 30. Heating system fuel or power supply? Check all that apply: [Natural Gas ❑Heating Oil ❑Kerosene ❑Solar ❑Electric ❑Wood ❑Coal ❑Other 30a. Heat conveyance system: Forced hot air ❑Heat Pump []Forced hot water ❑Steam ❑Radiant floor heat ❑Wood stove []Coal furnace []Fireplace ❑Electric Baseboard ❑Unvented Kerosene Heater ❑Other 31. Where is the heating system located? 32. Does the building have air conditioning? Oyes 0 32a. If YES, please check the appropriate type(s) ❑Central air conditioning ❑Window air conditioning unit(s) ❑Other, please specify 33. Does the building have any of the following? MRoom fans welling fans '~( , ❑Attic fans 34. is the building ventilated using the fan-only mode of the central FNAC system? ❑Yes [:]No 34a. If YES, What is the rated size of the fan? 35. Water Heater Type: []Gas ❑Electric ❑Other 36. Water heater location: (please describe) Potential Indoor Sources of Pollution 37. Has the building had termite or other pesticide treatment: Yes 0 Unknown 37a. If YES, please specify type of pest for which treatment was applied 37b. Approximate date of service 37c. Location of treatment within subject building 38. Has the building been recently (within the last six months) painted or remodeled? ❑Yes Isla 38a. If YES, please specify what was done, where in the building, and when: 39. Has new carpeting been installed in the building within the last year? E]Yes DNO 0 39a. If YES, when and where? 40. Is a dry cleaning service present in the building (check only one box)? ❑Yes, dry-cleaning performed on-site ❑Yes, dry-cleaning sent off-site, drop-off only ®No 41. Has the building ever had a fire? Yes No 42. Are there any cooking appliances in the building? KYes E No 42a. If YES describe: 43. Are the cooking appiiances vented by use of exhaust hoods? �es ❑ No 43a. Do the hoods vent to the outdoors? ❑ es 40 O 44. Is there an automatic dishwasher? Oyes Imo 44a. If YES, is the dishwasher ❑Commercial grade, or ❑Residential grade? 45. Is smoking allowed in the building? © es 0 45a. If YES, approximate number of smokers and level of smoking activity: (number of smokers) Light(< five cigarettes per day) Moderate (>five cigarettes per day) Heavy (one or more packs per day, >20 cigarettes per day) 46. Are air fresheners regularly used in the building? N (es ❑No 47. Are any of the following activities performed in the building? ❑Heating ❑Soldering ❑Welding ❑Painting (brush or roller) ❑Painting (spray) ❑Wood or metal finishing ❑Other activity involving chemical usage? (Please describe): 48. Please identify building cleaning and maintenance practices: Dusting Iy sweeping Vacuuming olishing (furniture, etc) r ashing orviaxing-floors- ❑Carpet cleaning ❑Other General building use of consumer products (please circle appropriate): Assume: Never = never used, Hardly ever = less than once/month, Occasionally = about onceimonth, Regularly = about oncelweek, and Daily = approximately onoe/day. Product Frequency of Use in Building Product Never Rarely Occaslongy Regularly— Dal Spray-on deodorants Aerosol deodorizers Insecticides Disinfectants Window cleaners Spray-on oven cleaners Nail polish or remover Flair sprays Solvents/Degreasers IX Paint or paint remover Miscellaneous s eci 49. Other comments: Figures/Additional Information Plan View: Sketch each floor and if applicable, indicate air sampling locations, possible indoor air pollution sources, preferential pathways and field instrument readings. `( Potential Outdoor Sources of Pollution: Draw a diagram of the area surrounding the building being sampled. If applicable, provide information on the spill locations (if known), potential air contamination sources (industries, service stations, repair shops, retail shops, landfills, etc.), outdoor air sampling locations, and field instrument readings. Also, on the diagram, indicate compass direction, locations of water wells, septic systems, and utility corridors if applicable, and a statement to help locate the site on a topographical Map. Complete the attached Chemical Products Inventory Form fie e.t� Arl p�'1� c�� ,� M 02_ Axu-ezr Paw- ec ly P-A- 2io? �. `x2-4 a � � /65 /`t 1Q •Jr� fo.�s Salta �' l l�h wd* 5445(v- A«txr,d-- -Frok";y rprnl r.� fi/64 . r)f�lt poWAr �-- j V-& Vory l� /4doii 06, -T v Wc. ,Ss got'Ap@ 5 n. i I ' I t i ; I kr N M w i rn K,1 Ti Z. i 1 : i r I • : I RESIDENTIALICOMMERCIAL/RETAIL QUESTIONNAIRE INDOOR AIR ASSESSMENT SURVEY This form must be completed for each building involved in an indoor air investigation. Preparer's name �,CA T4 � ��` V "� Date prepared 1 ( 13 Preparers affiliationt Telephone number 4 OCCUPANT: Name Address 4 city b Telephone number What is the best time to call to speak with you? Are you the❑Owner, VRenter, ❑Other of this Structure? Total number of occupants/persons at this location? 2- Average daily occupant/visitor population: persons. Number of children? Ages? How long have you occupied this location? 4 OWNER OR LANDLORD: Name S" W., ,��/,� �1TS,�OC► (If different from occupant) Address Telephone number AM'" 5$6- g933 Land Use and Building Construction 1. Type (Check appropriate responses): M Residential Commercial DOffice []Warehouse OStrip Mall 2. Age of the building? years. 3. Number of floors (stories) 1 4. Area of the building (square feet) 5. Is the building insulated? Yes No B. Flow well is the building sealed? Number of elevators in the building B. Condition of the elevator pits (sealed, open earth, etc.) 9. Above-ground structure construction materials (check all that apply): J]Wood ❑Brick []Concrete []Cement block []Other 10. General description of building construction materials�� (Li 11. Does the building have windows that can be opened? NYes o 1 la. If YES, indicate number and type(s) of window(s): 11b. If YES, describe the frequency and duration of window opening: S V 12. Does the building have doors? CRYes ❑No 12a. If YES, indicate number and type(s) of door: 12b. If YES, describe frequency and duration of door opening: 13. Foundation Construction (check all that apply): Concrete slab on grade ❑Fleldstone ❑Concrete block ❑Elevated above ground/grade Full Basement ❑Crawlspace ❑Other [NOTE: If the building does not have a basement, go to question 24.] 14. Basement?ZJYes, ❑No &-Se-nvol-' 1 "vv� Crawl Space? ❑Yes, ❑No 14a. If YES, under how much of the building floor space? % 15. Is the basement Dfl/nished, or❑unfinished? 16. If finished, how many rooms are in the basement? 16a. How many are used for more than 2 hours/day? 17. Composition of basement floor(check all that apply) F[Concrete ❑Tile ❑Carpeted ❑Dirt ❑Wood ❑Other(describe) ? 17a. If concrete, is the floor ❑Sealed ❑Unsealed ❑Painted Coveredwf. i� ❑Cracked ❑Other(please specify) 18. Are the basement/foundation walls Poured concrete ❑Cement block. ❑Stone ❑Wocu ❑Brick ❑Other 19. Are the basement/foundation walls ❑Sealed ❑Unsealed ❑Unknown 20. Does the basement have a moisture or water infiltration problem (check one only)? ❑Yes, frequently (3 or more fimes/yr) ❑Yes, occasionally (1-2 times/yr) ❑Yes, rarely (less than 1 time/yr) fi;jNo 21. Does the basement ever flood (check one only)? ❑Yes, frequently (3 or more times/yr) ❑Yes, occasionally(1-2 times/yr) ❑Yes, rarely (less than 1 time/yr) SjNo 22. Does the basement have any of the following? (check all that apply) ❑Floor cracks, ❑Wall cracks ❑Sump ❑Floor drain ❑Other hole/opening in floor (describe) (Identify all potential soil gas entry points and their size (e.g., cracks, voids, pipes, utility ports, sumps, drain holes, etc.), and any fluid accumulated. 23. Are any of the following used or stored in the basement(check all that apply) ❑Paint ❑Paint stripper/remover ❑Paint thinner ❑Metal degreaser/cleaner ❑Gasoline ❑Diesel fuel [,Solvents ❑Glue [-]Laundry spot removers ❑Drain cleaners ❑Pesticides Water and Sewage 24. What is the source of drinking water for the building (check all that apply)? ,8Public water supply ❑Bottled water ❑Private Water Well. If private well, please answer following: ❑Drilled Well ❑Driven Well ❑Dug Well ❑Other (Specify) Water Well Specifications (if applicable) Well Diameter Grouted or Ungrouted Well Depth Type of Storage Tank Depth to Bedrock Size of Storage Tank Feet of Casing Describe type(s) of Treatment ❑Other, please specify 23. Are there taste and/or odor problems with the water supply? ❑Yes, ❑No If YES, please describe How long has the taste and/or odor problem been present? 24. Is the water chlorinated, brominated, or ozonated? ❑yes, ❑no, ❑unknown 25. Does the building have a private well for purposes other than drinking? ❑Yes No If YES, please describe purpose of the well: 26. Does the building have a septic system? Yes No Not used ❑Unknown 27. How is sewage disposed? Public Sewer �ISeptic ❑Tank ❑Leach Field ❑Other(Specify) 28. What is the distance from the water supply well to septic system (if applicable)? feet 29a. Are septic tank additives used? ❑Yes ❑No ❑Unknown. If so, what type? 29. Is there standing water outside the building (pond, ditch, swale)? ❑Yes ❑No Pleating, Ventilation, and Air Conditioning 39. Heating system fuel or power supply? Check all that apply: datural Gas ❑Heating Oil ❑Kerosene ❑Solar ❑Electric ❑Wood ❑Coal ❑Other 30a. Heat conveyance system: f R Forced hot air ❑Heat Pump ❑Forced hot water ❑Steam ❑Radiant floor heat ❑Wood stove ❑Coal furnace ❑Fireplace ❑Electric Baseboard ❑Unvented Kerosene Heater [-]Other 31. Where is the heating system located? fit 32. Does the building have air conditioning? ❑Yes [ No 32a. If YES, please check the appropriate type(s) ❑Central air conditioning ❑Window air conditioning unit(s) ❑Other, please specify 33. Does the building have any,of the following? ❑Room fans voWrr_ f"' tv bA hovls ❑Ceiling fans ❑Attic fans 34. Is the building ventilated using the fan-only mode of the central HVAC system? ❑Yes [:]No 34a. if YES, What is the rated size of the fan? 35. Water Heater Type: as Electric ❑other 36. Water heater location: (please describe) Potential Indoor Sources of Pollution 37. Has the building had termite or other pesticide treatment: ❑Yes ❑No ❑Unknown 37a. If YES, please specify type of pest for which treatment was applied 371b. Approximate date of service 37c. Location of treatment within subject building 38. Has the building been recently (within the last six months) painted or remodeled? ❑Yes ❑No 38a. If YES, please specify what was done, where in the building, and when: 39. Has new carpeting been installed in the building within the last year? ❑Yes ❑No 39a. If YES, when and where? 40. Is a dry cleaning service present in the building (check only one box)? ❑Yes, dry-cleaning performed on-site ❑Yes, dry-cleaning sent off-site, drop-off only ❑Nc 41. Has the building ever had a fire? ❑Yes ❑No 42. Are there any cooking appliances in the building? FN es o 42a. If YES, describe: 43. Are the cooking appliances vented by use of exhaust hoods? NYes ❑ No 43a. Do the hoods vent to the outdoors? ,[ Yes [-]No 44. Is there an automatic dishwasher? ❑Yes §2No 44a. If YES, is the dishwasher ❑Commercial grade, or ❑Residential grade? 45. Is smoking allowed in the building? ❑Yes � 45a. If YES, approximate number of smokers and level of smoking activity: (number of smokers) light (< five cigarettes per day) Moderate (L>five cigarettes per day) Heavy (one or more packs per day, ?20 cigarettes per day) 46. Are air fresheners regularly used in the building? ,dyes kyt crrl}5c (>C o, %V( ,) IFINo ) 47. Are any of the following activities performed in the building? CIFeating DSoldering 'VVelding Painting (brush or roller) ❑Painting (spray) E.Wood or metal finishing []Other activity involving chemical usage? (Please describe): 48. Please identify building cleaning and maintenance practices: Xry usting � sweeping acuuming KPol . (furniture, etc) aching or waxing floors arpet cleaning []Other General building use of consumer products (please circle appropriate): Assume: Never = never used, Hardly ever.= less than once/month, Occasionally = about once/month, Regularly = about once/Week, and Daily = approximately once/day. Product Frequency of Use in Building Product Never Rarely occasionally Regularly Dail Spray-on deodorants Aerosol deodorizers Insecticides Disinfectants Window cleaners S ra -on oven cleaners Nail polish or remover YI Hairsprays Solvents/Degreasers Paint or paint remover Miscellaneous (specify) 49. Other comments: Figures/Additional Information Plan View: Sketch each floor and if applicable, indicate air sampling locations, possible indoor air pollution sources, preferential pathways and field instrument readings. Potential Outdoor Sources of Pollution: Draw a diagram of the area surrounding the building being sampled. if applicable, provide information on the spill locations (if known), potential air contamination sources (Industries, service stations, repair shops, retail shops, landfills, etc.), outdoor air sampling locations, and field instrument readings. Also, on the diagram, indicate compass direction, locations of water wells, septic systems, and utility corridors if applicable, and a statement to help locate the site on a topographical map. Complete the attached Chemical Products Inventory Form Chemical Product Inventory Form Building Occupant Building Address 6v 1 k l City, State, Zip Code Field InvestigatorO-c? 7-) C To Date Field Instrument Used : :. :� .::. . . .. ...; com.merciial,name;:;::.:.: �.:..:.:..:::.:.:.:..:...:.:.:..; `dis enaer:. ® ..container::.:. manufactureretc. ::.: :::.: ::::..::....::.:::.::::.:.::.:::.::..::.:..:.:..:.......::.::..:.:.. :.::::::.:..::.....:..:.:..:::.:.:::..:..:::......... .........:......::.. _ 40 0 ur k Olt 32- rrz►� to Z r yr U I' '? c-•4 (. t hA ". 2.6 r. cr Q�cx"t —ivops n.2[ 245 C t� rr ,1, Z.c,-q �tjac� A d Q5U 34-v' 1 1�i�zlr�+n ���•s � �Gtn 25 0� C r 1�►�-� � l i i i Kra rl �i ....; ! 4-1 V-1 1 1 KK 1 1 I jr 1 1 1 ! i f i i P-14 ' i I ... K 1 1 i,!; RESIDENTIALICOMMERCIALIRETAIL QUESTIONNAIRE INDOOR AIR ASSESSMENT SURVEY This form must be completed for each building involved in an indoor air investigation. Preparer's name 6&&welr -,�i Date prepared Preparer's affiliation kT-C- Telephone number '-)a(Dr 2Sj—/63-3 OCCUPANT: Name - d lt— Address 141 cityP-w�- c Telephone number q(�tp What is the best time to call to speak with you? Are you the POwner, ❑Renter, ❑Other of this Structure? Total number of occupants/persons at this location? Average daily occupant/visitor population: persons. Number of children? PA- Ages? _ How long have you occupied this location? )V OWNER OR LANDLORD: Name (If different from occupant) Address Telephone number Land Use and Building Construction 1. Type (Check appropriate responses): Residential Commercial ❑Offlce ❑Warehouse ❑Strip Mall 2. Age of the building? years. 3. Number of floors (stories)_ f 4. Area of the building (square feet) VVa, • 5. Is the building insulated? 9 Yes No 6. How well is the building sealed? 7. Number of elevators in the building 8. Condition of the elevator pits (sealed, open earth, etc.) 1111?" 9. Above-ground structure construction materials (check all that apply): Wood ❑Brick ❑Concrete ❑Cement block ❑Other 10. General description of building construction materials 11. Does the building have windows that can be opened? ,ZYes ❑No I Ia. If YES, indicate numfcer and t pe(s) cf window(s): i 11 b. If YES, describe they frequency and duration of window opening: 12. Does the building have doors? Wes No 12a. if YES, indicate number and type(s) of door: 12b. If YES, describe frequency and duration of door opening: n-1 b •�1 ir+ti�� 13. Foundation Construction (check all that apply): oncrete slab on grade pwv� Fieldstone ❑Concrete block []Elevated above round/grade 1 lNFull Basement �� rt,ase v+tia.�.� -l0b`?,6 16%Voy— ��-�-- ❑Crawispace ❑Other [NOTE: If the building does not have a basement, go to question 24.] 14. Basement?,gYes, ❑No Crawl Space? ❑Yes,Po 14a. If YES, under how much of the building floor space? % 15. Is the basement PTinished, or❑unfinished? 16. If finished, how many rooms are in the basement? ' 16a. How many are used for more than 2 hours/day? Uu-, 17. Composition of basement floor(check all that apply) Concrete Tile Carpeted ❑Dirt ❑Wood ❑Other(describe)J-1mry-_caye-gLuz, ? 17a. If concrete, is the floor ❑Sealed --sue 6"r\ ❑unsealed ❑Painted ❑Covered ❑Cracked ❑Other(please specify} 18. Are the basement/foundation walls Rcured concrete cement block ❑Stone ❑Wood ❑Brick ❑Other ? 19. Are the basement/foundation walls ❑Sealed ❑Unsealed Unknown 20. Does the basement have a moisture or water infiltration problem (check one only)? ❑Yes, frequently (3 or more timeslyr) IDYes, occasionally (1-2 timesfyr) ❑Yes, rarely (less than 1 timehyr) XJNc 21. Does the basement ever flood (check one only)? ❑Yes, frequently (3 or more times/yr) ❑Yes, occasionally (1-2 times/yr) ❑Yes, rarely(iess than 1 time/yr) 'ONO 22. Does the basement have any of the following? (check all that apply) []Floor cracks, ❑Wall cracks ❑Sump Floor drain ❑Other hole/opening in floor (describe) (Identify all potential soil gas entry points and their size (e.g., cracks, voids, pipes, utility ports, sumps, drain holes, etc.), and any fluid accumulated. 23. Are any of the following used or stored in the basement (check all that apply) ®Paint ❑Paint stripper/remover Po Paint thinner ❑Metal degreaser/cleaner ❑Gasoline ❑Diesel fuel ❑Solvents []Glue OLaundry spot removers—f"�PUSA ❑Drain cleaners ❑Pesticides Water and Sewage 24. What is the source of drinking water for the building (check all that apply)? ublic water supply Bottled water ❑Private Water Well. If private well, please answer following: ❑Drilled Well ❑Driven Well ❑Dug Well ❑Other(Specify) Water Well Specifications (if applicable) Well Diameter Grouted or Ungrouted Well Depth Type of Storage Tank Depth to Bedrock Size of Storage Tank Feet of Casing Describe type(s) of Treatment []Other, please specify 23. Are there taste and/or odor problems with the water supply? []Yes, ❑No If YES, please describe How long has the taste and/or odor problem been present? 24. Is the water chlorinated, brominated, or ozonated? ❑yes, ❑no, ❑unknown 25. Does the building have a private well for purposes other than drinking? Yes ]VhNC) Plu If YES, please describe purpose of the well: 26. Does the building have a septic system? ❑Yes ❑No ❑Not used ❑Unknown 27. How is sewage disposed? XPublic Sewer ❑Septic ❑Tank ❑Leach Field ❑Other(Specify) 28. What is the distance from the water supply well to septic system (if applicable)? feet 29a. Are septic tank additives used? ❑Yes [:]No ❑Unknown. If so, what type? 29. Is there standing water outside the building (pond, ditch, swale)? Yes J900 Heating, Ventilation, and Air Conditioning 30. Heating system fuel or power supply? Check all that apply; glatural Gas ❑Heating Oil ❑Kerosene ❑Solar ❑Electric ❑Wood ❑Coal ❑Other 30a. Heat conveyance system: orced hot air Heat Pump ❑Forced hot water ❑Steam ❑Radiant floor heat ❑Wood stove ❑Coal furnace ❑Fireplace ❑Electric Baseboard ❑Unvented Kerosene Heater ❑Other 31. Where is the heating system located? 32. Does the building have air conditioning? ❑Yes ` ;No 32a. If YES, please check the appropriate type(s) ❑Central air conditioning ❑Window air conditioning unit(s) ❑Other, please specify 33. Does the building have any of the following? ❑Room fans ❑Ceiling fans ❑Attic fans 34. Is the building ventilated using the fan-only mode of the central HVAC system? ❑Yes 34a. If YES, What is the rated size of the fan? 35. Water Heater Type: as L Electric ❑Other 38. Water heater location: (please describe) &.a��,�+, Potential Indoor Sources of Pollution 37. Has the building had termite or other pesticide treatment: ❑Yes 0 Unknown 37a. If YES, please specify type of pest for which treatment was applied 37b. Approximate date of service 37c. Location of treatment within subject building 38. Has the building been recently(within the last six months) painted or remodeled? E]Yes �o 38a. If YES, please specify what was done, where in the building, and when; 39. Has new carpeting been installed in the building within the last year? [ Yes 0 39a. If YES, when and where? 40. Is a dry cleaning service present in the building (check only one box)? ❑Yes, dry-cleaning performed on-site E]Yes, dry-cleaning sent off-site, drop-off only 41. Has the building ever had a fire? ❑Yes Pqo 42. Are there any cooking appliances in the building? Yes 10 MNo 42a. If YES, describe: 43. Are the cooking appliances vented by use of exhaust hoods? Yes " U No 43a. Do the hoods vent to the outdoors? Yes No 44. Is there an automatic dishwasher? Yes No 44a. If YES, is the dishwasher r,ommerciai grade, or Residential grade? 45. Is smoking allowed in the building? ❑Yes [53&o 45a. If YES, approximate number of smokers and level of smoking activity: (number of smokers) Light (<five cigarettes per day) Moderate (>five cigarettes per day) Heavy (one or more packs per day, ? 20 cigarettes per day) 46- Are air fresheners regularly used in the building? bi-es—Oe e-46i�AA ❑No 47. Are any of the following activities performed in the building? ❑Heating []Soldering ❑iNelding ❑Painting (brush or roller) ❑Painting (spray) ❑Wood or metal finishing ❑Other activity involving chemical usage? (Please describe): 48. Please identify building cleaning and maintenance practices: usting Dry sweeping OOacuuming Polishing (furniture, etc) dashing or waxing floors—gyp' arpet cleaning lao�- Other General building use of consumer products (please circle appropriate): Assume: Never = never used, Hardly ever = less than once/month, Occasionally about once/month, Regularly = about once/week, and Daily = approximately once/day. Product Frequency of Use in Building Product Never Rarely OccaslongL Regularly Dail Spray-on deodorants Aerosol deodorizers Insecticides Disinfectants Window cleaners Spray-on oven cleaners Nail polish or remover Hairsprays Solvents/Degreasers Paint or paint remover Miscellaneous (specify)_ 49. Other comments: Figures/Additional Information Plan View: Sketch each floor and if applicable, indicate air sampling locations, possible indoor air pollution sources, preferential pathways and field instrument readings. Potential Outdoor Sources of Pollution: Draw a diagram of the area surrounding the building being sampled. If applicable, provide ir:formaticn on the spill locations (if known), potential air contamination sources (industries, service stations, repair shops, retail shops, landfills, etc.), outdoor air sampling locations, and field instrument readings. Also, on the diagram, indicate compass direction, locations of water wells, septic systems, and utility corridors if applicable, and a statement to help locate the site on a topographical map. Complete the attached Chemical Products Inventory Form Chemical Product Inventory Form I / Building Occupant k, 0 Building Address `�b2 `�` - City, State, Zip Code W%- Field Investigator Date I- 12-rl Field Instrument Used t td .....:.:..... :..:...:.......: . ............:..::.:...........: Produc.:::::: : :::::. : ::'::: :: redients:in the �(commercial : .:',�.,; ; ° ;�.:.:. ....... . . Volat�le:Ing :: ....-.- :..........:.:....:::.,.. ..:.:...:....::...::...::::.:....:.... :.: Quantity.:::. :. :.:......:::: :::::::. ::. Prod u dispenser:.:tyPe�.:0ontainer..:.. . ............ ...... ::::sire manufacturer etc: a G 61 73 T � ssa 146�, U°I WOC Fmk Gw p—5,1c (�f Pok,.e„r�L SCO&lied P6"'t Foci/v Tqjk-l'r� a�c6 periv�V'e� �cv►ti.c� �� !2 a� Chemical Product Inventory Form Lj Building Occupant M-'a — Buildingg Address S-D P 14,*k � Clty, State, Zip Code dvv, i'til`� Field Investigator Date 1 -I2---l� Field Instrument Used VA Product Description (cdnimerclafhame, Volatile Ingredients in the dispenser type, cointalner Quantity product size manufactu'rer, etc. A+# 0'aeg 40 41-f, i 01 d • 1� 1 04- v, .z NMI Pk.1F4" AW" % Clmo T� 5d-f�lea knlic- srelr i � ' 3a- 6:2� If It Jul co fdy-GSA 86eA tea+ cq- �tuz�c� '30-L a:L- C�?iu2ir Free ^� 3 (yak 1 s Jn,�/Pc5t i 7z G � e a 1�5 Spa.. 3 S� r L.-F', s�Q -e 2> O xr ,Arm Sol if%a 1 �W"()--r � Ft-e4.4 35 e-�- T cam-dvw- 10-. Tw fa4- cxt4j- r : i i : • � .4 S i � S � I ' : i i I bS� 1 : N t E ; (f Qw i € i t = I i I t E ♦:S_. Rd i : r� :. vXV " w. RESIDENTIAL/COMMERCIALORETAIL QUESTIONNAIRE INDOOR AIR ASSESSMENT SURVEY This form must be completed for each building involved in an indoor air investigation. Preparer's name,�dti.G?fif1 ; ��5ruc�S�tl" ate prepared Preparer's affiliation Telephone number. 10b Z59 —/63�'� OCCUPANT: Name Dr- Address J 1 T j `' Alre- City Telephone number. tHr - UGA� +7c What is the best time to call to speak with you? Are you the Mowner, ❑Renter, [_-]Other of this Structure? Total number of occupants/persons at this location? z Average daily occupanttvisitor population: 2 persons. Number of children? .&""' Ages? How long have you occupied this location? ,,•�r�ef�j OWNER OR LANDLORD: Name (if different from occupant) Address_ Telephone number Land Use and Building Construction 1. Type (Check appropriate responses): Residential ❑Commercial ❑Office ❑Warehouse ❑Strip Mall 2. Age of the building? years./? 3. Number of floors (stories) 1 4. Area of the building (square feet) 2 5. Is the building insulated? RYes No j 6. How well is the building sealed? �l 7. Number of elevators in the building - 8. Condition of the elevator pits (sealed, open earth, etc.) 9. Above-ground structure construction materials (check all that apply): ood rick Concrete ❑Cement block []Other 10. General description of building construction materials 11. Does the building have windows that can be opened? [ Yes 0 11 a. If YES, indicate number and type(s) of window(s): `�• des o 11b. If YES, describes t e tequency and duration of window opening: 12. Does the building have doors? IN o 12a. If YES, indicate number and type(s) of door: 12b. If YES, describe frequency and duration of door opening: lU 13. Foundation Construction (check all that apply): ❑Concrete slab on grade ❑Fieldstone ❑Concrete block ❑Elevated above ground/grade NFu li Basement ❑Crawlspace ❑Other [NOTE: If the building does not have a basement, go to question 24.1 14. Basement?Ryes,.❑No Crawl Space? []Yes, 50o 14a. If YES, under how much of the building floor space? % 15. Is the basement 2�lnished, or❑unfinished? 16. If finished, how many rooms are in the basement? 16a. ,-low many are used for more than 2 hours/day7 17. Composition of basement floor(check all that apply) Moncrete ❑Tile ❑Carpeted ❑Dirt ❑Wood ❑Other(describe) ? 17a. If concrete, is the floor X,Sealed ❑Unsealed ❑Painted ❑Covered ❑Cracked ❑Other (please specify) 18. Are the basement/foundation walls oured concrete Cement block ❑Stone ❑Wood ❑Brick ❑Other ? 19. Are the basement/foundation walls ❑Sealed ❑Unsealed RJnknown 20. Does the basement have a moisture or water infiltration problem (check one only)? ❑Yes, frequently(3 or more times/yr) ❑Yes, occasionally (1-2 times/yr) Yes, rarely (less than 1 time/yr) No 21. Does the basement ever flood (check one only)? ❑Yes, frequently(3 or more times/yr) ❑Yes, occasionally (1-2 times/yr) ❑Yes, rarely (less than 1 time/yr) NNo 22. Does the basement have any of the following? (check all that apply)