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HomeMy WebLinkAboutPart 2 - Offsite Indoor Air, Sub-Slab Vapor and Outdoor Air (Part 2 - Offsite Indoor Air, Sub-Slab Vapor and Outdoor Air Field Investigative Reportx9E5D1) ❑Floor cracks, ❑Wall cracks ❑sump 9Floor 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) aint Paint stripper/remover ❑Paint thinner ❑Metal degreaser/cleaner ❑Gasoline []Diesel fuel ❑Solvents !aundry lue spot removers :]Drain cleaners ❑Pesticides 'water and Sewage 24. What is the source of drinking water for the building (check all that apply)? 24Public water supply RBot<ied water Aov e ❑Private Water Well. If private well, please answer following: I_,`Drillea Well ❑Driven Well ❑Dug Well ❑Other(Specify) Water Well Specifications (If applicable) V'E'eie Diameter Grouted or Ungrouted Well Depth 'hype 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 Flow long has the taste and/or odor problem been present? 24. Is the water chlorinated, brominated, or ozonated?Dyes, Ono, ❑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 Elwood ❑Coal ❑Other 30a. H conveyance system: Morced hot air ❑Heat Pump ❑Forced hot water ❑Steam ❑Radiant floor heat ❑Wood stove ❑Coal furnace ❑Fireplace ❑Electric Baseboard ❑unvented Kerosene Heater [jOther 31. Where is the heating system located? Se e 32. Does the building have air conditioning? ❑Yes NNo 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 ❑No 34a. If YES, What is the rated size of the fan? 35. Water Heater Type: R as Electric ❑Other 36. Water heater location: (please describe) v� - - Potential Indoor Sources of Pollution 37. Has the building had termite'or other pesticide treatment: ❑Yes U0 nknown 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? Nes ❑No 38a. If YES, please specify what was on , where in the building, and when: hive + 39. Has new carpeting been installed in the building within the last year? ❑ es �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 QYes, dry-cleaning sent off-site, drop-off only 0 41. Has the building ever had a tire? ©4es �Na 42. Are there any cooking appliances in the building? E9es ❑No 42a. If Y S, describe: 43. Are the cooking appliances vented by use of exhaust hoods? Ewes ❑ No 43a. Do the hoods vent to the outdoors? ❑Yes n 44. Is there an automatic dishwasher? Ryes Oal- Lk v-A. L0 44a. If YES, is the dishwasher ❑Commercial grade, or residential grade? 45. Is smoking allowed in the building? ❑Yes gNo 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? rN es Ce-je4 ' dO'e•r►V'Xg o 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: rRhusting Kp'ry sweeping Macuuming olishing (furniture, etc) Owashing or waxing 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 oncelmonth, Regularly = about once/week, and Daily = approximately once/day. Product Frequency of Use in Building Product Never Rarely Occasionally Re ular! ©ail S ra on deodorants Aerosol deodorizers Insecticides Disinfectants Wndow cleaners Spray-on oven cleaners Nail polish or remover Hair sprays Solvents/De reasers Paint or paint remover Miscellaneous (specify) 49. Other comments: . 7,15 U. Tka, t 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 De-e A - &LJ Building Address k- City, State, Zip Code jlkyA Id Field Investigator, Date /z/-1p Field Instrument Used P"'A W 6iqriptlo comma 1'.. N A Will"i nai P ......................ize u acture Sl 216 w- O-Z PL 04, 0z t 12- A 22 cz- "Sa gsk CVS Y+ 16' TiIP- �k a-e. Ov-WA-7-ft-4 .t6PA'i- 37 mt, gv4i -Z2 Q^. 6. �S o� �CJn�G1+l� �C��IUe� `�y CIA Lk� Id 'rl Soep lz oz CS�Csu �)AP \33' 6�loi�ln) 1-4 - 31�1 - 1 Its �x n ` ca � � . q� P�vx rT 5 va. w5 I 1 ru 5 U7� rllo9 r 14 '-Ih t nruLr ©r l / .�.Q co ="A-f s trot r - 1N�rnQ,.n ori- ��� � �r a a Lf 4 in .2lr. .3-P di 69) 2�S � �b c� CO- . r All ............ ........... . ...... ..... ................................. 7------------ bL cn .......... i s a)J _ N • RESIDENTIALICOMMERCIALIRETAIL QUESTIONNAIRE INDOOR AIR ASSESSMENT SURVEY This form must be completed for each building involved in an indoor air investigation. Preparer's name -11rh rer/ , 4 r- _ r- Date prepared Preparer's affiliation- Telephone number fad " `�"/1y.*;;-3 OCCUPANT: Name�_1Yr1/I�vr�v✓�i :J r Addressy -- city. � . Telephone number �f� '" 59 What is the best time to call to speak with you? Are you the,00wner, ❑Renter, ❑Other of this Structure? Total number of occupants/persons at this location? Average daily occupant/visitor population: persons. Number of children? A Ages? How long have you occupied this location? OWNER OR LANDLORD: Name (If different from occupant) Address Telephone number Lana Use and Building Construction 1. Type (Check appropriate responses): btesidential ❑Commercial ❑Office ❑Warehouse ❑Strip Mall 2. Age of the building? ^years. 3. Number of floors (stories) 1 7 4. Area of the building (square feet) 1517 9A fl St r r lei 5. Is the building insulated? r es No /J� 6. How well is the building sealed? o4 �' 7. Number of elevators in the building .414 8. Condition-of the elevator pits (sealed, open earth, etc.) A44" 9. Above-ground structure construction materials (check all that apply): ?fN ood Brick ❑Concrete ❑Cement block ❑Other 10. General description of building construction materials 44Z4 11. Does the building have windows that can be opened? Yes No 11a. If YES, indicate nulnber and typ ) of window(s): { — 2.►�"_ 11b. If YES, describe the frequency and duration of window opening: 12. Does the building have doors? es No 12a. If YES, indica a number and type(s) of doo e 12b. If YES, describe frequency and duration of door opening: 13. Foundation Construction (check all that apply): oncrete slab on grade Fieldstone ❑Concrete block ❑iElevated above ground/grade ❑Full Basement ZCrawispace ❑Other [NOTE: If the building does not have a basement, go to question 24.1 14. Sasement?XYes, ❑No Crawl Space? Yes, (:]No 14a. If YES, under how much o the building floor space?�°5D 15. is the basement Patiroshed, or�Zunf ilsheO 16. If finished, how many rooms are in the basement? 3 16a. How many are.used for more than 2 hours/day? .9 A-,TMA- 17. Composition of basement floor(check all that apply) Concrete Tile ®Carpeted — Dirt ❑Wood ❑Other(describe) ? 17a. If concrete, is the floor ❑Sealed ❑Unsealed &tPainted Covered ❑Cracked ❑Other(please specify) 18. Are the basementffoundation 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 time/yr) jXNo 21. Does the basement ever flood (check one only)? ❑Yes, frequently (3 or more times/yr) ❑Yes, occasionally (1-2 times/yr) E]YYes, rarely(less than 1 time/yr) PO 22. Does the basement have any of the following? (check all that apply) ❑Floor cracks, ❑Wall cracks Flisump loor 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) ZPaint ❑Paint stripper/remover ❑Paint thinner []Metal degreaser/cleaner []Gasoline ❑Diesel fuel ❑Solvents —q� lue laundry spot removers ®Drain cleaners ❑Pesticides Water and Sewage 24. What is the source of drinking water for the building (check all that apply)? $ZPublic water supply ❑Bottled water E]Prsvate Water Well. If private well, please answer following: ❑Drilled Well ❑Drivers Well ❑Dug Well ❑Other(Specie) Water Well Specifications (if applicable) `Well Diameter Grouted or Ungrouted yell Depth Type of Storage Tank Depth to Bedrock Size of Storage Tank Feet of Casing Describe type(s) of Treatment ❑Other, plaass 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, Ono, ❑unknown 25. Does the-building have a private well for purposes other than drinking? ❑Yes 0 No If YES, please describe purpose of the well: 26. Does the building have a septic system? ryes JZNo ❑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 ZVo 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: ff orced hot air Heat Pump ❑Forced hot water ❑Steam El Radiant floor heat ❑Wood strove ❑Coal furnace ❑Fireplace ❑Electric Baseboard ❑Unvented Kerosene Heater ❑Other t 31. Where is the heating system located? Mom_{, 0G Q,. 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 Calling 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: 5Gas Electric ❑Other 1, 36. Water heater location: (please describe) CGl Potential Indoor Sources of Pollution 37. Has the building had termite or other pesticide treatment: ❑Yes r 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 JKNo 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)? les, dry-cleaning performed on-site crc_nv�r," � ' ❑ C . Yes, dry-cleaning sent off-site, drop-off only ❑No 41. Has the building ever had a fire? ®Yes PO 42. Are there any cooking appliances in the building? Yes '[:]No 42a. If YES, descr'be: 43. Are the cooking appliances vented by use of exhaust hoods? es No 43a. Do the hoods vent to the outdoors? -- s-.— 4k 'gio 44. Is there an automatic dishwasher? Oyes 0 44a. If YES, is the dishwasher OCommercial grade, or residential grade? 45. Is smoking allowed in the building? (]Yes PNO 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) Leavy (one or more packs per day, ?20 cigarettes per day) 46. Are air fresheners regularly used in the building? ❑Yes Y�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 .Mbry sweeping Vacuuming olishing (furniture, etc) aching otwaxing-f ors-- 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 oncelw eek, and Daily = approximately once/day, Product Frequency of Use in Building Product . Never Rarely Occasionally Regularly Dail Spray-on deodorants Aerosol deodorizers Insecticides INsinfectants Window cleaners Spray-on oven cleaners Nail polish or remover Hairs ra s Solvents/De reasesb 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 lAr, Building Address City, State, ZID Code Field Investigator 04 /1 W Date f - 1.3-16 Field Instrument Used &lh-- :."..V illatille-Ingredlents.1in. t Ua ................ . .. .', .. .. manufacturer .. 0"Qt4 Ac)( fa7,,L4- 114913 94 (Ira V r,rie 0 S el- 3Q a- UOYOY. 54 iaCXL AA 8��M -D Gn�j 99y-- Or+r-b 016 t q±1 I-Wwn b-i��Jt S~ i ACV C-1 'off-. jw t Chemical Product inventory Formby &MIQA Building Occupant A LC r-3 Building Address_ City, State, Zip Code hit Field Investigator Date 1�-- b Field Instrument Used Product Description (commercial name, Quantity Volatile Ingredients in the dispenser type, container Product size manufacturer, etc. i3av 1 + � T 6 r `3' d o f — vN ,�P Ho FaXLALL y 9 ti `iqQ Ina u - A� 33G 6mix17, 20 I Gr�tc� ee� has p0qAtnkh OW CdLrno �a rC � a am ox, Qom. � - 'pe IQ 1/1) A&-;)7 -671-c d:Q 13� me Valvolixe v7ipj F -3 - /mil /a �- �� lb� �ana x rr7vr wl Gk,MO wti�'Ske"tit !rtw 6� d ZO �/ `J'�I'f ZE�+�'�/Zr �'C�' �'2P11'1}4�'LCQ�t.1iC'.�'._'(✓f� �L� ��_ d y r 7 c -�ri e •9 OLD Chemical Product Inventory Form Building Occupant r!x"d ne';h Building Address City, State, Zip Code e*na-- t Field Investigator C G Date_ -46 Field Instrument Used GeV Product Description (commercial name, quantity Volatile Ingredients in the dispenser type, container Product size, manufacturer, etc. bo"), SLI/a 5 P F e 6i t. .. ,r I� La r�- r ,5 kI dam. `llto i .�� P44 up ed M O'D w Il i rJ r . LjKf t i jot, f�^" 'f ram.✓�` A yr�o�t aii to 6� o �fmov,! �IU (3) ( � d Cis p(,art �� 2uo��N1 !% I I ' AOP i i :.. - i i r;r-; ; ' 44� I i i I I ... l . I, ..:.. ..:..... ' L AN. . .... .: ..... '.��.1. .., . .. .. .... .... .. ............ .. ..... . ............. ...... .. .. .. i : Z :' '• .� i E+E t : : ............: ....:... ..; i I i e e I i I I tie i It F7 1 Qr ` . . : : ...:......: RESIDENTIAUCOMMERCIAL/RETAIL QUESTIONNAIRE INDOOR AIR ASSESSMENT SURVEY This form must be completed for each building involved in an indoor air investigation. Preparer's name Date prepared Preparer's affiliation A-rc, koc—.L-m Telephone number OCCUPANT: Name Cr.✓i�1� �L Address + - City Qyy\-ten , kT. Telephone number What is the best time to call to speak with you? Are you the gowner, ❑Renter, ❑Other of this Structure? Total number of occupants/persons at this location? �z Average daily occupant/visitor population: persons. Number of children? Ages? --� ' How long have you occupied this location? c, ar1G°� OWNER OR LANDLORD: Name (If different from occupant) Address Telephone number Land Use and Building Construction l 1. Type (Check appropriate responses): sidentiat Commercial ❑Office ❑Warehouse 'Strip Mall 2. Age of the building?.�-yeafc,-, 3. Number of floors (stories) 4. Area of the building (square feet) _ ( � 0 8. is the building insulated? rN es o 8. How well is the building sealed? i. Number of elevators in the building_ �i�� 8. Condition of the elevator pits (sealed, open earth, etc.) 9. Above-ground structure construction materials (check all that apply): ood Brick ❑Concrete [,'.-.Cement block ❑Other 10. General description of building construction materials i l. Does the building have windows that can be opened? NYes []No I Ia. If YES, indicate number and type(s) of window(s): 11 b. If YES, 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 frequency and duration of door opening: K) 13. Foundation Construction (check all that apply): ❑Concrete slab on grade ❑Fieldstone ❑Concrete block ❑Elevated above ground/grade Ek&Basement 1 ,1t Mrawlspace ❑Other [NOTE: If the building does not have a basement, go to question 24.1 14. Basement?QRyes, ❑No Crawl Space?XYes, ❑No 14a. If YES, under how much of the building floor space?.1 L 0 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? V 17. Composition of basement floor(check all that apply) oncrete Tile �,Cirt ❑Wood ❑Other(describe) ? 17a. If concrete, is the floor M ealed unsealed ❑C ainted ❑Covered ❑Cracked ❑other(please specify) 18. Are the basement/foundation walls ❑Poured concrete ❑Cement block ❑Stone ❑Wood ❑Brick ;�Other 19. Are the basement/foundation wails ❑Sealed ElUrsealed ,Mnknicnown 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 tirmelyr) KNo 21. Does the basement ever flood (check one only)? []Yes, frequently (3 or more times/yr) ❑Yes, occasionally(1-2 times/yr) ❑�Ges, rarely (less than 1 time/yr) 0 22. Does the basement have any of the following? (check all that apply) f 9moor cracks,, ' r"4 (Nall cracks q ❑Sump floor drain LA r r-c ❑Other hole/opening 1r 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 int stripper/remover aint thinner Metal degreaser/cleaner ❑Gasoline ❑Diesel fuel olvents l u e A-aundry spot removers ❑Drain cleaners ❑Pesticides Water and Sewage 24. Wh t 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„*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 NO If YES, please describe purpose of the well: 26. Does the building have a septic system? ❑Y s ;"0 Not used ❑Unknown 27. How is sewage disposed? fublic 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 theae 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: atural Gas Heating Oil ❑Kerosene ❑Solar ❑Electric ❑Woad ❑Coal ❑Other 30a. Heat conveyance system: ❑Forced hot air ❑Heat Pump orced hot water Steam ❑Radiant floor heat ❑Wood stove ❑Coal furnace EFireplace ❑Electric Baseboard ❑Unvented Kerosene He ter Cflther s ft cL _ 31. Where is the heating system located? 32. Does the building have air conditioning? ryes 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? aom fans Meiling 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: KGectric ❑Other 36. Water heater location: (please describe) Potential Indoor Sources of Pollution 37. Has the building had termite or other pesticide treatment: Myes 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? es No 38a. If YES, please specify what was clone,where in the building, and when: 39. Has new carpeting been installed in the building within the last year? WO s 39a. if YES, when and where? 40. Is a dry cleaning service present in the building (check only one box)? s, dry-cleaning performed on-site es, dry-cleaning sent off site, drop-off only ❑No 41. Has the building ever had a fire? UYes QgNo 0 42. Are there any cooking appliances in the building? es No 42a. If YES, describe: 43. Are the cooking appliances vented by use of exhaust hoods? s No 43a. Do the hoods vent to the outdoors? N'es N0 44. Is there an automatic dishwasher? s e �No 44a. If YES, is the dishwasher ❑Commercial grade, or 'residential grade? 45. Is smoking allowed in the building? Yes o f3rP-U. pw� -5v,-,Oa_ 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? rKYes—CCS ❑No 47. Are any of the following activities performed in the building? 'Heating ❑Soldering E]Welding inting (brush or roller) Maoodinting (spray) or metal Finishing ❑Other activity involving chemical usage? (Please describe): 48. Please identify building cleaning and maintenance practices: usting ry sweeping acuuming olishing (furniture, etc) shi!�g-ei�!�-flve�s Carpet cleaning +a W9❑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 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 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, cn the diagram, indicate compass direction, locations of water wells, septic systems, and utility corridors if applicable, and a statement to help Iccate the site on a topographical map. Complete the attached Chemical Products Inventory Form Chemical Product Inventory Form Building Occupant Building Address City, State, Zip Code Field Investigator Date Field Instrument Used Product f'60--d6c.d. 8SCH00.6.6 (dommerclaill:Aime ......... Ingredients in the' .. Quantity dispenser type;container Product. ... d...... Ct" size; M a n Lfictu re ri;.Ofc3; ......... Chemical Product Inventory Form Building Occupant 14 41 Building Address City, State, Zip Code Field Investigator Cate Field Instrument Used A44 Produ`ct��Descriptlon (commercial name :Volatile;lriredients:in the Quantity .dispenseutype;container 6.1 a :Manufactur9er,-:etc ;. :. 1ZoZ- r 331 vi 131 So t 0,, )� �AI1r h 2 [L "' di 1 � 00 3� ,f 73a d� cW co.ram d Aorxi � �o-a�'►-�- art d� I tL P, U,V-qA"'R—Rom r x 1®0 ASS - itta S c� / K" —60 R,6r Oa4- 69 Aij Q So i ql = --/v 13SS U-TS 6-4 Zf IN .. j i i i .. ? zq- le) Y I : I 1 j ! RESIDENTIAL/COMMERCIAL/RETAIL QUESTIONNAIRE INDOOR AIR ASSESSMENT SURVEY This form must be completed for each building involved in an indoor air Investigation. Preparer's name C47 Jt Date prepared 42-4-V Preparer's affiliation..____ ATc Af./o 6&19 Telephone number b OCCUPANT: Name � P P ki Address—__. City g p-7,G rf\A" ., P1 1 Telephone number bi} `5411 _?We What is the best time to call to speak with you? Are you the ❑OwnerARenter.. DOther of this Structure? Total number of occupants/persons at this location? - Average daily occupant/visitor population: persons. Number of children?A_M__` Ages? How long have you occupied this location7O'/n-10,T�-� OWNER OR LANDLORD: Name e-ja44 , (If different from occupant) Address Telephone number 406-- 53�^ 5T+1 LawvA�( Land Use and Building Construction 1 Type (Check appropriate responses): Nesidential Commercial ❑Office ❑Warehouse []Strip Mall 2. Age of the building? years:" 73- 3. Number of floors (stories)WW1tV&-ed r 4. Area of the building (square feet) 5. Is the building insulated? , es ❑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.)&/t 9. Above-ground structure construction materials (check all that apply): TBrood ick ❑Concrete ❑Cement block ❑Other J 10. General description of building construction materials IrrI06F 11. Does the building have windows that can be opened? Yes ❑No 11 a. If YES, indicate number and type(s) of window(s): r� 5 'f 11b. If YES, describe the frequency and duration of window opening: 12. Does the building have doors? Yes No 12a. If ES, indicate number and type(s) of door: ! �---. V r 12b. If YES, descri a frequenjcy and duration of door opening: 13. Foundation Construction (check all that appiy): 9oncrete 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 24.1 14. Basement?XYes, ❑No Crawl Space?xYes, ❑No 14a. If YES, under how much of the building floor space?EQ010 15. is the basement❑finished, or Unfinished? 16. If finished, how many rooms are in the basement? 3 16a. Flow many are used for more than 2 hours/day? /VAI - 17. Composition of basement floor(check all that apply) oncrete The ❑Carpeted ❑Dirt ❑Wood ❑Other(describe) ? 17a. If concrete, is the floor ❑Sealed Rnsealed 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 Onsealed ealed 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) AW 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) 0 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) amt Paint strippertremover ❑Paint thinner ❑Metal degreaser/cleaner ❑Gasoline ❑Diesel fuel ❑Solvents ❑Glue ❑Laundry spot removers ❑Drain cleaners ❑Pesticides Water and Sewage 24. W4at is the source of drinking water for the building (check all that apply)? eMpublic water supply Bottled water ❑Private Water Well. If private well, please answer following: ❑Drilled Well ❑®riven Well ❑Dug Well ❑Other(Specify) Water Well Specifications(if applicabie) Well Diameter Grouted or Ungrouted Vveil Depth 'hype of Storage Tank Depth to Bedrock Size of Storage Tank Feet of Casing Describe typs(s) of Treatment ❑Other, please specify 23. Are there taste and/or odor problems with the water supply? ❑Yes, []No If YES, please describe Now 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 MNo 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)? JEJ.Yes X.No Heating, Ventilation, and Air Conditioning 30. Heating system fuel or power supply? Check all that apply: M,Natural Gas Heating Oil ❑!Kerosene ❑Solar ❑Electric ❑Wood ❑Coal ❑Other 30a. Hea .conveyance system: Forced hot air *seat Pump Forced hot water ❑Stearn ❑!,adiant floor heat ❑Wood stove ❑Coal furnace ❑Fireplace ❑Electric Baseboard FlUnvented Kerosene Heater ❑Other 31. Where is the heating system located? /_ &�- 32. Does the building have air conditioning? ❑Yes XNo 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? r-I'Moorn fans Ce`Iing fans-:a Attic fans 34. Is the building ventilated using the fan-only mode of the central HVAC system? Dyes ,gN0 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 t&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? ❑Yes ❑No 38a. If YES, please specify what was done, wherein 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 ANo 41. Has the building ever had a fire? Dyes ❑No 42. Are there any cooking appliances in the building? '91Yes ❑No 42a. If YES, describe: 43. Are the cooking appliances vented by use of exhaust hoods? .. fes ❑ No 43a. Do the hoods vent to the outdoors? Yes Alo 44. Is there an automatic dishwasher? Ayes ❑No 44a. If YES, is the dishwasher ;9❑Commercial grade, or esidential grade? 45. Is smoking allowed in the building? es No 45a. If YES, approximate number of smokers and level of smoking activity: (number of smokers) Light (<five cigarettes per day) Moderate (?eve cigarettes per day) Leavy (one or more packs per day, > 20 cigarettes per day) 46. Are air fresheners regularly used in the building? ❑Yes ,ONo 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: .Pusting Dry sweeping FPacuuming Polishing (furniture, etc) ❑Washing or waxing 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 once/month, Regularly = about once/Week, and gaily = approximately once/day. Product Frequency of Use in Building Product Never Rarely Occaslonall s, Regularlyd7aii Spray-on deodorants fleresol deodorizers Insecticides Disinfectants , Window cleaners Spray-on oven cleaners Nail polish or remover Hairsprays Soivents/De 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 Chemical Product Inventory Form Building Occupant Building Address OV, City, State, Zip Code -'T Field Investigator K). Date Field Instrument Used N66166t Des6rliptl .......... ercial. me, ...... ingredients in e Sp yp ntalln df Ize manufacturer s r. etc, 10 An O-Z 02 04- :,—Ae C2 .569.,e Cw oz- ple 3z 07- 9A Oz M 0-C Qeiq ZZ OZ rh'M)c ul az- 4.- !V-C-> 62. I+r OA 66 doroX T-AL+ S-ceo1' CA, Aiul. Am, 0(14 SkIrr— -V C.-2. 44- 1/2- 94 �7 -rd i je-f f36,jl 32- oz 6 tqMe�, Z-CA-�P-,C f��1 Cz) .,, .(?) C�g,t\+ r 6d k"U'4 I-Ao J PA 15t PL k, o6 cc,,�4.- p,.+ I �. Cy1)) 0 C�Cf s f- 3X 62. 6o4- �J toP9�o ��Oessa7 Potxr R,�'�n Uon$Q..+ SPAY d 8' I �Z I I ijio e •. . . ' i : i j : ' 1 .. N : ...: . :... ..: _ 4 fijr ... VI Za : I : y Qz t. .:.. .:.. .:.. ..: RESIDENTIAUCOMMERCIAURETAIL QUESTIONNAIRE INDOOR AIR ASSESSMENT SURVEY This form must be completed for each building Involved in an indoor air investigation. Preparer's name � J[ V-M V S'C 9-- Gate prepared Preparer's affillation rG A ft D c �A(?jr Telephone number 40 G •-- 21" q 10 3 J OCCUPANT: Name D(,vyl a-, :bo-V a A# Address Sro 9 l7��' -r4evt City E e /`h AO /'iT Telephone number Llp(.,- %T -99 q .N What Is the best time to call to speak with you? Are you the owner, ❑Renter, ❑Other of this Structure? Total number of occupantsipersons at this location? rQ Average daily occupant/visitor population: persons. Number of children? Ages? How long have you occupied this location? A003 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 g 2. Age of the building? years. 3. Number of floors (stories) 4. Area of the building (square feet) '*''7 000 5. Is the building insulated? ,XYes ❑No 6. How well is the building sealed? 7. Number of elevators in the building�l,�1 8. Condition of the elevator pits (sealed, open earth, etc.) A 9. Above-ground structure construction materials (check all that apply): Wood Suer jnsJ J 1013rick Concrete ❑Cement block ❑Other i 10. General description of building construction materials r 11. Does the building have windows that can be opened? 9�Yes No 11a. If YES, indicate numbe and type(s) of window(s): - —M T 11 b. If. YES, describe the frequency and duration of window opening: S !/'1 CJ 12. Does the building have doors? Yes No 12a. If YES, indicate number and type(s) of door: a 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 MFull Basement Crawispace ❑Other [NOTE: If the building does not have a basement, go to question 24.I 14. Basement? Yes, [:]No Crawl Space? ❑Yes,Po 14a. If YES, under how much of the building floor space? /OU % 15. Is the basement finished, or unfinished? PaAj 16. If finished, how many rooms are in the basement? 3�n;s cc- ma=rat Unt���s� 16a. How many are used for more than 2 hourslday? 5 17. Composition of basement floor(check all that apply) Concrete Tile ;ftk64 ftkh1kak Carpeted-Uf&j W r ❑Dirt ❑Wood ❑Other(describe) ? 17a. If concrete, is the floor ❑Sealed Snsealed ainted ❑Covered ❑Cracked ❑Other(please specify) 18. Are the basement/foundation walls oured concrete I2"`X 30 S(�4a'v". Waek 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 time/yr) �, 1 .5� 3.re*,+.f(or'"0,� 'HNo 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 Jther 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 &Faint stripper/remover Faint thinner Metal degreaser/cleaner []Gasoline E]Diesel fuel ❑Solvents ❑Glue ❑Laundry spot removers ODraln cleaners ❑Pesticides Dater and Sewage 24. What is the source of drinking water for the building (check all that apply)? RIPublic water supply Bottled water ❑Private Water Well. If private well, please-answer following: []Driied Well F riven Well nDug Well [Other(Specify) Water`, fell Specifications (if applicable) WeN Diameter Grouted or Ungrouted Well Depth p 1'ype cf Storage"Ir ank Depth to Bedrock _ Size of Storage Tank Feet of Casing Describe type(s) of Treatment E]Other, please specify 23. Are there taste and/or odor problems with the water supply? E]Yesj�]No If YES, please describe Hcw long has the taste and/or odor problem been present? 24. Is the water chlorinated, brominated, or ozonated? ❑yes,ywno, ❑unknown 25. Does the building have a private well for purposes other than drinking? ❑Yes allo - 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 ;KNo Heating, Ventilation, and Ah, 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 RtA ^4-L L � Unvented Kerosene Heater ;A�� Q�c, l�tr;I- r +�-� a. ❑Other I 31. Where is the heating system located? ).S6ih xutL_ 32. Does the building have air conditioning? Dyes RNo 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? Dyes ❑No 34a. If YES, What is the rated size of the fan? 35. Water Heater Type: ❑Gas ®F-lectric ❑Other 36. Water heater location: (please describe) 63--rome � Potential Indoor Sources of Pollution 37. Has the building had termite or other pesticide treatment: ❑Yes 12No ❑Unknown 37a. If YES, please specify type of pest for which treatment was applied NIA 37b. Approximate date of service 37c. Location of treatment within subject building N 38. Has the building been recently (within the last six months) painted or remodeled? Ryes yNo 38a. If YES, please specify what was done,where in the b4ilding, and when- �03 s 39. Has new carpeting been installed in the building within the last year? ❑Yes J5�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 ,5?No 41. Has the building ever had a fire? ❑Yes 'UNo 42. Are there any cooking appliances in the building? lYes ❑No 42a. If YES, describe: 43. Are the cooking appliances vented by use of exhaust hoods? ❑Yes X No 43a. Go the hoods vent to the outdoors? ❑Yes ❑No 6 " 44. Is there an automatic dishwasher? Eyes ❑No 44a. If YES, is the dishwasher ❑Commercial grade, or X-Residential grade? 45. Is smoking allowed in the building? ❑Yes 5No 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 PNo 47. Are any of the following activities performed in the building? []Heating ❑Soldering ❑Welding � ❑Painting (brush or roller) ❑Painting (spray) ❑Woad or metal finishing Other activity involving c mical usage? (Please describe): 48. Please identify building cleaning and maintenance practices: ❑Dusting ❑Dry sweeping [OVacuuming L, A e k ouu' ❑Polishing (furniture, etc) ❑Washing or waxing floors RCarpet 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 Buiiding Product. Never -Rarely Occasionally Regularly Dail -Spray-on deodorants Aerosol deodorizers Insecticides Disinfectants Window cleaners x Spray-on oven cleaners Nail polish or remover Hairsprays Solvents/Degreasers Paint or paint remover Miscellaneous (specify) 49. Other comments: 4tV� J4�Z" 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 .17,ps- 1'7 -tA City, State, Zip Code go Zel"A P P AAT Field Investigator, - <1 JA IN K-M'k-&5 Zf IL Date 11124 D Field Instrument Used -A At Product-1136i-Mptlb m e Quantl Y V010110 11"Or9di)n- ts in he. 0 �- ntare, . ; Product size anu rtc. Aaact %of 4/d *-X Pa4AA NAIDC 3a 6Z ak- LA L?� cam,^ Ij VW-Twi-e- 29 -rho-" 6a r-tow ol- kit Po' 11 0 �xk�e- Chemical Product Inventory Form Building Occupant 1)%Vil 4 bo-,jr(q- go W Building Address Sibs 13'"n City, State, Zip Code -?xj2g�=Q lAn Field Investigator 6-4 /.LI.A Date Field Instrument Used Des-Mptio n -----�-.::;.VoIatIIe Ingredients MMQ an I U a. Q t C sbr.type n manufacturer I 12a-- I nwm& na vlq4 MIAWM AAiv0J 3) &t'-Wow,k4i C Pal, IAJ SS IkO3 U4Ktoj IL T:Sf Mlos",5Wn KL is 39 Mr,(656v &,,6, rlkis� OWWV5 Pto Px(YLj V"Al'f .3.0 or-f'-- (.9 5� Mir"_ Le 0-c- W"wi- Axq�Grvul T T,6 e7v,Y- 3:2 b-z-, &LA-Ati-f Clfra"- 5�Alkw G.V9 C'UAM ODA F1 4 M WN I pl- r%'CR -r,6 La 10 avk4- 13'4� 5e�� / P, — I �/ JC Chemical Product Inventory Form Building Occupant Building Address ous City, State, Zip Code Field Investigator 1%M0 11"fl— Date IV Field Instrument Used tVP- ..Proucl"d t Dejcrllp . ....... ..t.s. in t 9 ttY Product.;.::;;.......Ize-nanu manufacturer' . .. wz_ CIV -(VA P, tom - A LY, P% 6b_' 04hvw� 1,2 1 t we I I &'10"*J614 A Aff ,O-AP F/I how "4*t Mkop_ V 'x Ar-e /if -ecjk 3M Ile- a,#V1iAA0-f _I I r 6,A,.v Atoll f 2- 1)4)0 64 JAk_cr�fc rVllek Pof 511 Oyip WE po, 1 v r l b b':xe'l PVC-,#,A— 31-s p aAct Pwisk oil 1�,,rA (s) �:�c 6]l,gym.: �►At ID !2�1✓�le -AA-I— V,+lf���. �.oV4 dietiW ovrE 3/ Pat G pd6�A- 6 � Chemical Product Inventory Form Building Occupant .. P bcw La- ji0 7a7 Building Address 1-7'�'N City, State, Zip Code -:r Field Investigator ?j Da Field Instrument Used 66; n ' jl '- Volati I I . ...e n ts her0h e0a::name K Product -"Ponta ::':size;:manufacturer; Q-)A U 4 tklk Mno 6 9 4-b4 SN-k", Auz -2-- txnA 4J6 A. R A(A->o ?IT l� L-& -0\ Lt 0-j-, RA V-1 MiA i <-' Z51. Jalvr 3e---O� Z-. S ru. I U JQ >40V"' A,), 7'(AVVdj 1 v,, vN V e UA V,.Ab.j qL'-k e.. 2 �1 fi l vz Z �D g 2 spr' xZ S-9 4 2.4 o 7- /VftWP'64, A/,*- OW, � �b fit �Y�O/ 06514 q-4 �� y 1 O'Z- &JOY Z2 0z sir Y IAV14 - �'Afe u �M4. i b fl gam)4 ry oz. Yoy .J�.t�►1"'9i I'1MiG�tll�l. Od I �D'Z tip' .��.r� y`�►�.' Z.o h4r 50a? dA"-VNS - HOT- 5 7- ca"'Va f, Ott4crfv Chemical Product Inventory Form Building Occupants �a q°# Building Address b�i �V City, State, Zip Code Field Investigator Sk JL 0 Date Field Instrument Used A))- �cri #io u�t.D es c Volatile ingredisnts.in.the..:.;_ :::::... . .:.....:....:.:..:... .:..... :...... :. . . . .,. ..:.......,..:...,......:Quantity.::.::�.:::..�:;:.:::::�: :............:..:..:.::::......: .sneer.:. size.-manufacturer; etc. :.:... ::........ . :.::..:;., dY_ 1 lot bi h / . q 2 07 cxisec-'4 40A V o z v -d a coof CL 7 ..o X �r`11 r4� Arnne►�" J t.5�— Z v l d.' W' 0' -� Svz. s r �kl kei ..Ma(r » a•r_ Grown ��b�A*�d arc, /r�/!a!� Aomp sai..r We r sue,,( f 5 411 ........................ ............. slia Proll Z eyc/,L 01./ C4rbxr-e4or Cfe-Aw- Ack R�-ji 5 7 ap j J 0 2- I*A4 th I L4.pd,,.V tql�i -b/p 9;1 P6 iAfw- Coe 66 krWd SlekiM (wood) Z. oP14; -64 r-av- color Car jo-&,34, -ar4,r6qOr 3,z 60 A oZ I&Zkeew, 1E ^w -4yA Chemical Product Inventory Form Building Occupant Building Address City, State, Zip Code PDate 17- -ID Field Investigator Field Instrument Use .. ...... 77W6.66t Descr the atill M COM Quanu dspqnse t :size; manufacturer CS, tz C4-,.,tK but&C rV1 ........ ... I c .....:.... 17 ZP Lz ........ ... s-n ................ .. .......... RESIDENTIAL/COIV MERCIALfRETAIL QUESTIONNAIRE INDOOR AIR ASSESSMENT SURVEY This form must be completed for each building involved in an indoor air investigation. Preparer's name urove.r ) La"^Akegkoy� Date prepared -- 11-lD Preparer's affiliation A-X kS506 � j7ne Telephone number y01 ` Z59 - 1033 OCCUPANT: Name PaAld oc. e.nmy- Address 51 Z. N 1 T " Ave. City_ 5o�ma�1 Telephone number Ola- fig ""1531 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? 1 Average daily occupanttvisitor population: persons. Number of children? Ages? 3 How long have you occupied this location OWNER OR LANDLORD: Name 5e-e "a y-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?3—years. 3. Number of floors (stories) 4. Area of the building (square feet) 5. Is the building insulated? Yes No 6. How well is the building sealed? ` f-// 7. Number of elevators in the building A./A 8. Condition of the elevator pits (sealed, open earth, etc.) { 9. Above-ground structure construction materials (check all that apply): Wood Brick Concrete - s ►� Cement block [-]Other 10. General description of building construction materials wood/'�ri('L 11. Does the building have windows that can be opened? &Yes No 11 a. If YES, indicate number and type(s) of window(s): 11 b. If YES, describe the frequency and duration of window opening: --- MC 12. Does the building have doors? Yes No 12a. If YES, indicate number and types f door: C -e — int 12b. If YES, describe frequenc nd duration of door opening: 13. Foundation Construction (check all that apply): ❑Concrete slab on grade ❑Fieldstone ❑Concrete block 0FElevated above ground/grade ull Basement ❑Crawlspace ❑Other (NOTE: If the building does not have a basement,go to question 24.] 14. Basement?Ayes, ❑No Crawl Space? ❑Yes,, WNo 14a. If YES, under how much of the building floor space?.&0/o 15. Is the basement❑finlshed, or❑unfinished?d"""a 16. If finished, how many rooms are in the basement? 5 16a. How many are used for more than 2 hours/day? 17. Composition of basement floor(check all that apply) Concrete Tile Carpeted-f44' haj ]Dirt ❑Wood ? ❑Other(describe) 17a. If concrete, is the floor ❑Sealed R3Unsealed ❑Painted ❑Covered . ®Cracked-- ems []Other(please specify) 18. Are the basementifoundation walls ❑K'Poured concrete ❑Cement block ❑Stone ❑Wood ❑Brick ❑Other. 19. Are the basement/foundation walls Sealed -fo�v4 Unsealed ❑Unknown 20. Does the basement have a moisture or water infiltration problem (check one only)? ❑Yes, frequently (3 or more times/yr) Dyes, occasionally (1-2 times/yr) ❑Yes, rarely (less than 1 time/yr) JgNo 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) P N0 22. Does the basement have any of the following? (check all that apply) ❑Floor cracks, ❑Wall cracks ❑Sump RFioor drab; � fill, cvw. ,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 Y`.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 WeR ❑father(Specify) Water Well Specifications (if applicable) Well D meter Grouted or Ungrouted Weli Depth Type of Storage Tank Depth to Bedrock Size of Storage Tank Feet of Casing Describe type(s) of Treatment ❑other, please specify 23. Ars there taste and/or odor problems with the water supply? ❑Yes, Xi o If YES, please describe How long has the taste and/or odor problem been present? AO 24. Is the water chlorinated, brominated, or ozonated? ❑yes, Ono, ❑unknown 26. 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 ONot used ❑Unknown 27. How is sewage disposed? ,KPublic Sewer ❑Septic ❑Tank ❑Leach Field ❑Other(Specify) 28. What is the distance from the water supply well to septic system (if applicable)? IV4- 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 VNo Heating, Ventilation, and Air Conditioning 30. Heating system fuel or power supply? Check all that apply-, Natural Gas NIa�W /i" Heating Oil ❑Kerosene ❑Solar ❑Electric ❑Wood ❑Coal ❑Other 30a. Heat conveyance system: ❑Forced hot air Heat Pump Forced hot water —Forced ❑Radiant floor heat ❑Wood stove ❑Coal furnace ,�Firepiace�►�r.�� ❑Electric Baseboa ❑Unvented Kerosene Heater ❑Other 31. Where is the heating system located? -- 32. Does the building have air conditioning? so 0 32a. If YES, please check the appropriate type(s) ❑Central air conditioning ❑V"dindow air conditioning unit(s) ❑Other, please specify 33. Does the building have any of the following? ❑Room fans JN eli'ng fans FlAtUb fans 34. Is the building ventilated using the fan-only mode of the central HVAC system? []Yes ;QNo 34a. If YES, What is the rated size of the fan? 35. Water Heater"hype: ❑Gas lAtlectric Other 36. Water heater location: (please describe) 5 -Q12 Potential Indoor Sources of Pollution 37. Has the building had termite or other pesticide treatment: Oyes No ' nUnknown 37a. If YES, please specify type of pest for which treatment was applied 37b. Approximate date of service_ 370. location of treatment within subject building 38. Has the building been recently (within the last six months) painted or remodeled? []Yes PKNo 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 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 g]No 41. Has the building ever had a fire? Dyes 'SNo 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? Yes Iffl No 43a. Do the hoods vent to the outdoors? as N'o 44. Is there an automatic dishwasher? es No 44a. if YES, is the dishwasher r'lCornmercial grade, or f Residential grade? 45. Is stroking allowed in the building? ❑Yes �OVo 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 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: [MDusting ry sweeping ,®Vacuuming Polishing (furniture,Jetc) Vllashing or waxing floors ❑Carpet cleaning ❑Other General building use of consumer products (please circle appropriate): Assume: Dever = never used, Hardly ever = less than oncelmonth, Occasionally = about oncelmonth, Regularly = about oncetweek, and Daily = approximately oncelday. Product Frequency of Use in Building Product Never Rarely _Occasiona!!y Regularly Dail Spray-on deodorants Aerosol deodorizers Insecticides Disinfectants Window cleaners Spray-on oven cleaners Nail polish or remover Hairsprays Solvents/Dogreasers 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 PaAIA, ¢-tabu Building Address 5j7 /??- Ave- City, State, Zip Code gMg8nQM p4T Field :investigator(PIA Date Field Instrument Used AzA edu. lent$ -.Q ercial name o able ngr q nt.ty.:�. , rod .... ....... "'i3tc.ize, rn a n u6ct"'ur:'e'"r,:, '30L X,eAA air 11042 bee 1 &PC f- 144 4 A-IF=WA %1a4w_.K t _V X 4 j6"Y"u—,(-,--+ .x SO MA�VA*Q 1(k j0Z '2 P_ 0-2: JA)ai OA4A r&V6_.e 1%11' k ?> 6 old 51gks 4 SMXAA C)v $i51/ Rphold's-24Y �ev 14FL��O"L 61v Chemical Product Inventory Form Building Occupant 67 C/X) Building Address City, State, Zip do-de Field Investigator d V- Date Field Instrument Used VA Product ript.i o ba h .. Matile I ngredien.. . - I : Product:container..: :: sIze"manufactureq . . V0J-SP0,rT-)-w.&UMO-1 I Ito m L. PY-02-x Nffic e� .-'bAP 74 11�,L p"WL -ad Cot )4 A4�JjC,&t7, po-1 Arq fit, 3,4-3 L r �r,4er 91dw I 1A s aat lit Luc[ 1 3 jT-6 L, & SAW Win 01 P64 I Ispor 51,qKdwR CA lors 3 1145 L- "tic fu#, I Nor 9"1 b 0G.".%cr,I ---V— Ry &,V�l- a SSVqVj (ctlah-,F Cal iv woe-elf--'6-C-CAKk T dC gel*k�j o aj bx, a",c av-'� Pro-pni'e- CL4A 114 Chemical Product Inventory Form Building Occupant Peuj (ti--672-) Building Address j512. ;1 -ve City, State, Zip Code Field Invest1gator.C.4A.(,ary& Date I f Field Instrument Used Ag. P .............. .... ..... . M le In iv lients. .4io n a- Enan ..... ...... . 4vj V &MUVWIII�q� C—Al-AALI AV Ito '0-�& !Amkor�s kjw&4km, NoYOL t?"oe GI*APf' gd �ay 1!4tf'Walt LL4 2- 9.dj�ove— 4Y&Vj R-A )C04i SiZQ tAk S�we_ 50Y I p vw liae4d 1A 6AA1 --7. I OYJ4 bbAl^ jg_� g at UAM IQMJJA—. 61OZ'L Chemical Product Inventory Form Building Occupant 10/AAxl%4� (!�Cb=n nxr Building Address City, Statis, Zip Code Field Investigator Date Field Instrument Used injm :M:erciavnamej Qua ........... 0 ..gq.......Iner .. . ........... K�btc:,s1ze.,manu fmih Aafum vt 231omt 7.RP41k'L'!;%K'4-o I 4ef4l in AI Cross-j P0 46--orda ) C ►10 ft)is bqjute6j;h4�0 X3 41CM k W b "I IL pbff � n ice. ��r w 11WIWOVA04A (A' xry I ae L,'KctA h,,;de4 44 4 d Lufp- MAAIJVXV'b. w.. L6_1 1Z9 A ..I , b���1O y�, n f a �� v, 1�1'w omn 0)o A*�)414nawd� Li ..........................-) 6 Vtx-- 6 ;, L"L =- HaAi r� CN-¢4- t5 D 44,v► I z -in A jb �7 k)b, L/® Z e t/*)o ,,r 5 WC,04(.>LAO- �I 6—t t Min WaA a`s PoC�� pv;Hds 1hocf-3 A-Q 1 � �v7p��t w5 Pet&c X.7(z) .ram- #OPVL4. aq-�,�qn 0-2-- xe.asc =0 � �t.��c.�.•- �ryYD SG�.�k �-c'_t?� �i �j ��5 CZ.J 1 Fc, L1r 32 iJ ` 1 .off. ..1 2- •- �� 7�� m rill ew3. 7-1 s ............... w I I { N , If,4 I RES]DENTIALICOMMERCIAL/RETAIL QUESTIONNAIRE INDOOR AIR ASSESSMENT SURVEY This form must be completed for each building involved in an indoor air investigation. Preparer's name ,`? r V-12A\4 S-2-tA ..- Date prepared �� ! Preparer's affiliation ATC. A 1'fU G,akc S Telephone number 4-D - °� 03 3 OCCUPANT: N �eoj�, Address240 6W &A city �0-21;:1 ehy)1Aji, 7- Telephone number._W-51%& -6301 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: 21 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 1. Type (Check appropriate responses): esidential Commercial ❑Office ❑Warehouse ❑Strip Mall 2. Age of the building? _years. IVA � t �! 3. Number of floors stories t! f 4. Area of the building (square feet) I.N- + � 5. Is the building insulated? Yes ❑No 6. Flow well is the building sealed? Q an 7. Number of elevators In the building IV 8. Condition of the elevator pits (sealed, open earth, etc.) 44 to 9. Above-ground structure construction materials (check all that apply): �*ood Brick ❑Concrete ❑Cement block ❑Other 10. General description of building construction materials 11. Does the building have windows that can be opened? es No 11a. If YES, indicate number and type(s) of window(s): 11b. If YES, describe the frequency and duration of window opening: U joS YnL� 12. Does the building have'doors? Yes No 12a. If YES, indicate number and ty e(s) of door: f- s1�t ►1� �i�ss e�_� �- ouk�y r c C� r�t+Jl! 01 12b. If YES, describe frequency and duration of door opening: AIA 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 24.3 14. Basement?Oes, ❑No Crawl Space? ❑Yes,NVO 14a. If YES, under how much of the building flo r space?N% . . 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?, V—..--- 17. Composition of basement floor(check all that apply) 5TT' oncrete lle carpetedt2,1S in []Wood ❑Other(describe) ? 17a. If concrete, is the floor ❑Sealed ❑Unsealed ❑Painted ®Covered ❑Cracked ❑Other(please specify) 18. Are the basement/foundation wails oured concrete Cement block ❑Stone ❑1i ood ❑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 timeslyr) []Yes, rarely(less than 1 tlme/yr) lEInc 21. Does the basement ever flood (check one only)? ❑IYes, frequently (3 or more times/yr) ❑Yes, cccasionally (1-2 timeslyr) ['Yes, rarely(less than 1 timelyr) A<O 22. Does the basement have any of the following? (check all that apply) ❑Floor cracks, ❑Wall cracks ❑Sump Rf loor drain Other h /openin in floor (describe)kt17p l'.G�IA (h (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 RLaundry spot removers Drain cleaners ❑Pesticides Water and Sewage 24. Rat is the source of drinking water for the building (check all that apply)? ublic water supply ottled 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 tj 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?eyes, ❑no, ❑unknown 25. Does the building have a private well for purposes other than drinking? ❑Yes 1§�rNo If YES, please describe purpose of the well: 26. Does the building have a septic system? ❑Yes 'o Not used ❑Unknown 27. How is sewage disposed? ubfic Sewer Aeptic I []Tank Ell-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? Dyes ❑No ❑Unknown. if so, what type? 29. Is there standing water outside the building (pond, ditch, swale)? ❑ Yes PKO Heating, Ventilation, and Air Conditioning 30. Heating system fuel or power supply? Check all that apply: atural Gas Heating ail []Kerosene ❑Solar []Electric ❑Wood ❑Coal r ❑Other 30a. Heat conveyance system: ❑Forced hot air eat Pump tM Worced hot water v ❑Steam ❑Radiant floor heat ❑Wood stove ❑Coal furnace ❑Fireplace ❑Electric Baseboard ❑unvented Kerosene Heater ❑Other 31. Where is the heating system located? qv WaA oil 32. Does the building have air conditioning? KN eso 32 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 A �+ ❑Ceiling fans 10 ❑Attic fans �� 34. Is the building ventilated using the fan-only mode of the central HVAC system? KNo es 34a. If YES, What is the rated size of the fan? A Z - C_. 35. Water Heater Type: a Elesctric ❑Other 36. Water heater location: (please describe) Potential Indoor Sources of pollution 37. Has the building had termite or other pesticide treatment: Ys 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? FlYes 0 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 :RIO 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 s, dry-cleaning sent off-site, drop-off only XNO 41. Has the building ever had a fre? iic# 7 " ❑Yes o 42. Are there any cooking appliances in the building? es Nc 4 If YES, descri e: 43. Are the cooking appliances vented yduse of exhaust hoods? Ites o 43a. Do the hoods vent to the outdoors? ❑Y0 o 44. Is there an automatic dishwasher? es No 44a. If YES, is the dishwasher ❑co mercial grade, or �Kesidentlal grade? 45. Is smoking allowed in the building? FlYps �Ko 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? ❑dX-Nos 47. Are any of the following activities performed in the building? ❑Heating ❑Soldering ❑Welding ❑Painting (brush or roller) ❑Painting (spray) ❑Wood or metal finishing ❑ `h r acti ity involving chemical usage? (Please describe): t � c 48. Please identify w ding aning and maintenance practices: IRbusting 19Dry sweeping acuuming Polishing (furniture, etc) (, ❑Washing or waxing 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 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 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 information on the spill locations (if known), potential air contamination sources (industries, service stations, repair shops, retail shops, landfills, etc.), outdoor air sampling locatlons, 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 TUW "I Q, Building Address ' 3 1p 12th s4f, 1 City, State, Zip Code Field Investigator 5 7-6 A-, Date Field Instrument Used Product MM Volatile Ingroq1q. Qua ti dls '6nsqr Product--zyp%- ' size,�lmanu manufacturer 'etc. ... 01. owl Ot U)4 hP' a :7 j Lio-)-ia Idle 31W-&'l I re Luze r2) 2,-704- bi'A V2 f1A'x- -f 0q 3 �A A to Weo tW, t$,Jpet�S4�-&hjw,, 22-4q- Y 41 It-311YA� F k)" �,'AV (,te M,0 I- 0-t 'b V'o k - -(ba wt:i"-d G MVC dit —I(Iffa 61N Plak 'Fn-J ek-7 A-Ole — �/k Z41r-I Ao,442,1 6D#/e im ffi4o--A-VAPf" po qQ6 cdvi� I,46Pi Au*'-, 14M f� 12, p?- 2.4 &hl I e.r •2 "-"L- 7 C' Res's ph&/Mp 7p-z' !rPM7 6P#A llooc X-Ant Asyw -� /a 6:'!.- Af/�/e or/Mi 01w",-ko �'Pz- e-VIAI Chemical Product Inventory Form Building Occupant &0 a_ fAt Building Address In I Hh City, State, Zip Code ty-ma d Field Investigator -Date___// M Field Instrument Used ... ........ MMq 4 paw _ Volatile groqW.ts container;::: ::;:::.... Uct K.7.1 etc.:size':Manu acturer," A4 thdil slwe'1:4 4 11 J4_ Acx+iZ. AA&,r;w; I lc4,ltv W-eJ SOAAA 12- LA Pqy�I i_w' Sc.w a&6t4, Xpeb 2-U IJ it .z k4g*111W Z.,fr' AA1,<_ 341 1 c x7 7 s 4ej7� I RAA. Chemical Product Inventory Form ;A Building Occupant 'J �-' �- W Building Address -7/0 City, State, Zip Code Rj3. Q-90 AW Field Investigator C t,m IC,V-A Date / v Field Instrument Used ;:.:,:;;;Product:...::escripti.::.:..:.:..:...:..:. .:..: .�...::.,..:.::.... ::...,�.:...,..:.:.:.::.:.:...:........:: ::.::.. . .. ... .. .... Volatile Ingredients In Quantity Product .dlspenser..type,:container..' .:... ;'��`.',�::.:.:.�..�.....�::;:..:::,:°;:;;.....:.::.:.:�::....... ,,::°...: :::.:::;:.:.:.:�:�:;::.::::�::•.::.:::.�.:� :. .:.,.�.....�:.•:: .,.:si :manufa ze:. cturer etc. :: .. . ........... . :•.:::. :::::. ::....,:,:...:......... All IdA 1 Vue►rrt- /J/dc�4 Q I�oZ C.a�► er'►,` 1on L%hrr c:cn{ 1497, r ,./ tr lhGr�G! NO Z ! r- Ion'1004,il (610z- --r1II � s 'Co . °' u. -Z— vat xz -1=' All /�Ox r`h AMe- S LSA wwwn,5 ail 20 z Chemical Product Inventory Form Building Occupant fA;ik Building Address City, State, Zip Code y zAA-t, Field investigator V-9-AJSL,,Cr-- Date Field instrument Used Pi6es n comma c'a1:" am a Ingredients. n #qnta ner. ':`size"Manufacturer e c.TrMw A47o,, /tj e 41. -s /, f le L 4- q4, cmns 7-- 14.1 21,b &1<, ue V-4- L44L --fmlf Ldgy- a:f'n-6� 5 0&1 64114-dr I hs�v 'Aua Wjk Vmvl b 7- -' fi1j34-- r-6(#-1-S f fx M 'of I fill ijA wao<A V,+,6A 0/5 Chemical Product Inventory Form Building Occupant lbko UJA Building Address VV City, State, Zip Code E y .L erv. (1-1 WE Field Investigator_ < (aTt 169-ALk6V-*-- -Date- 1fp Field Instrument Used pal n i in Q V I t 9 a H9 Ingrqdjqnt tt uan ro uct:-:--::�: .......... etc.-1nanu aturer L Nike c f ' ' M4 all rrmf.-jA M) ,I O.-Afty 1Yk'&"e pre v /,q i, Volukr'.4_ck gjixt�j " -7- - - C'AL 61A 6-1-5 /eo-,-- krov4 fe,,47 14'tc�tr CAP-W /Z. 0 U e+ : ut ILd 1 t a i i I I �; �. .fro► ���-. r;YA `n. j � � � RESIDENTIAL/COMMERCIALIRETAIL QUESTIONNAIRE INDOOR AIR ASSESSMENT SURVEY This form must be completed for each building involved In an indoor air investigation. Preparer's name-00L GMW 11AAAAIT.1, � ,-kv-? Date prepared Preparer's affiliation lArTe- Telephone number lb i o •-2S' /D 3-3 OCCUPANT: Name Address ($` five- City _ lSOnn Telephone number LJ0& ~6r What is the best time to call to speak with you? Are you the t4owner, FRenter, _]Other of this Structure? Total number of occupants/persons at this location? Average daily occupant/visitor population: persons. Number of children? Ages? How long have you occupied this location? OWNER OR LANDLORD: Name r � (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) �'1 /00 5�A yamL 5. Is the building insulated? 5Yes 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.) P# 9. Above-ground structure construction materials (check all that apply): Wood ❑Brick ❑Concrete tga ` ❑Cement block ❑Other 10. General description of building construction materials 11. Does the building have windows that can be opened? W-Yes —yes 11 a. If YES, indicate nu m er and type(s) of window(s): ai 11b. If YES, d scribe the frIalluency and duration of window opening: 12. Does the building have doors? es No 12a. If YES, indicate number and type(s) of door: + 12b. If YES, describe frequency nd duration of door opening: 13. Foundation Construction (check all that apply): []Concrete slab on grade ❑Fieldstone ❑Concrete block ❑Elevated above ground/grade uil Basement Crawlspace ❑Other [DOTE: If the building does not have a basement, go to question 24.1 14. Basement?,MYes, ❑No Crawl Space? ❑Yes, �SNo 14a. If YES, under how much of the building floor space?/,sip % 16. Is the basement❑finished, or unfinished?/Q� 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 basementifoundation walls ,'Sealed Rnsealed ❑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) 0 22. Does the basement have any of the following? (check all that apply) ioor cracks, W&11 cracks Sun?p 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) KIM Lgy-alnt aint stripper/remover ❑Paint thinner [-]Metal degreaser/cleaner ❑Gasoline ❑Diesel fuel ❑Solvents Glue Laundry spot removers ®rain cleaners Pesticides Water and Sewage 24. at 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 ©river* Well ❑Dug Weli ❑other(Specify) Water Weil Specifications (if applicable) Well Diameter Grcuted or Ungrcuted Well Depth Type cf Storage Tank Depth to Bedrock Size of Storage Tank Peet 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 26. 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: ;ANatural 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? Dyes '�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 systerR? ❑Yes Pallo 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 '9No ❑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 glo 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 I�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 '*o 41. Has the building ever had a fire? ❑Yes 3KNo 42. Are there any cooking appliances in the building? 'LjNo 0 42a. If YES, describe: Saw '� /] 43. Are the cooking appliances vented by use of exhaust hoods? es No 43a. ®o the hoods vent to the outdoors? ,KYes ❑No 44. Is there an automatic dishwasher? KYes ❑No 44a. if YES, is the dishwasher Cr-lommercial grade, or 04Residential 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? Yes No 47. Are any of the following activities performed in the building? ,- p ❑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 [fit Vacuuming Polishing (furniture, etc) ashing or waxing floors�l�o w29ujC Carpet cleaning -5fe-I vein J Other General building use of consumer products (please circle appropriate): Assume: Bever = 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 Occasional! Regularly Dail S ra -on deodorants Aerosol deodorizers Insecticides Disinfectants Window cleaners Spray-on oven cleaners Nail polish or remover Hairsprays Solvents/Degreasers 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 Chemical Product Inventory Form Building Occupant bill 4 ge#14' 1164, Building Address 4114t I h"If it V e- City, State, Zip Code GQa4,124� 04 Field Investigator Date L- I-LO - - I - ` Z ' %*"-t4'Field Instrument used rodu t M.046criptio, HeA cla ,inaradiants-In.the." MAIne Ure . ......... 00 J-4 46 IMP 54UX PU� . � 6--' wNt 93 D-;,x- Let 4 lic-PA�nf �-oz AA 14A N,co Xrt-Mq Ion 564 OJI Itaeo b4m;d1kMA M gAre kfM56" I gla 2- T iu s - I SG I 5F Chemical Product Inventory Form Building Occupant 6;11'v A A Building Address #j�j ye- City, State, Zip Code Field Investigator Field Instrument Used ' t T -Doscrl q. :-'-:i-.--.-VqIatlIe Ingredle.pts is enser:.tantity p container ainer . -manufacturer:.,,,i3 sizes, :;,* "Irl:r44 & 59� N44'rao tA4 AW S6 r7)?r5b qj1 ^L- V 60 49eve4 VIN'15 owlqw 61 V 3"2 6q- oern V uue��'Ji At 5 WaA a� Ky 2-2 . d & 3D wnt • - h ter' -oo ReA 1U&p44Lo- ,5 b (0,) Fait Aq6 c 3frvc� -3a- n (-a) Sp i �. p 6�°f I /fin SZ ✓n-a i5�� L&rL �� s P f4L" - 31 l Chemical Product Inventory Form Building Occupant 1 + Building Address City, State, Zip Code Field Investigator_ C-Cm LR Date Field Instrument Used f-P d Do ...the.;ts Mn A %,-:Product." nW .................. li6 :::::::.size,,,manufacturer 61(w e4L.4 e-57-, ,/VX ........... Q/00-a,(iez S" cd 4 3)5 V eMLL, &L4� M04 YJAA% 5CM kaw Son. AWk 1-AUAbVPn fW1 4-4 V�w I Q-957- 0 �103 Peo&,rc� 12 6-io6um 5�0� -M Ki r�• v1 C�nk.s &sak AAom- Picks 31 6 X D04A-, o � 3 msso 6"o'm � i6k � t 'vi ve-r Q?44�- alLrr 25 .SA 5ra-WCA Old � (?OnA- A 21 a olw � lG 6:7- r) m V� � 6 FTV-Ke-A f/a-il, y � ��Aot�o 5k""O)v- r Chemical Product Inventory Form W-� Building Occupant -eI Building Address City, State, Zip Code Field Investigator Date L— Field Instrument Used P i6d 6 6t"Ci ......... ts . .............. Vollati le Ingredien .11n.th. Produ .di n C'wA &K-jk, 3 a' d:?,- �Tlrz�Lw (I f/fT,- AJ". 3 a - 6-?,'- AM PlV6416 64-.-z-�.tavol ) 5-b CLrt& 5" 2 01 V 6-1-1 `2 - ' ('-'MCV A9 Are &vr--- 0q, a 7, 5 MAI Trkv 3 A wit ?I lte-b Prim" 7q&ft L /2- (2- WI) Yo � I I � / � a� p�r rYL orr dW lr�j tx L4 )2- . Ito Z6� 6� ��t 5 - vra.���oi-�.Q. r a Ddt"�LTYam (=a0471 /dDR- -G Gq/L V .... ...... ........... . ............ (. ,.I 1. � .. � - . ................. In ........... to RESIDENTIAL/COMMERCIAL/RETAIL QUESTIONNAIRE INDOOR AIR ASSESSMENT SURVEY This form must be completed for each building involved in an indoor air investigation. Preparer's name r-_1 1.0 H ILP-Au J Z.c fl• Date prepared 6111,11 Preparer's affiliation ,A? G Arpi) u-Pte jr Telephone number tDG -' 9 — /� S3 OCCUPANT: Name &e �, sv« fL9J'2iUl Address 412 lt City ,9 U--Le/n A u, mT Telephone number lit) - 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? 2-- Average daily occupant/visitor population: o--1 persons. Number of children? -- Ages? How long have you occupied this location? OWNER OR LANDLORD: Name 4L- a4 .Sv+r- re.1y hI ck (if different from occupant) Address Telephone number . Land Use and Building Construction 1. Type (Check appropriate responses): NlResidential Commercial ❑OfFce ❑Warehouse ❑Strip Mall 2. Age of the building? years. NjfXi p4_�L 3. Number of floors (stories) 3 S7" . � 4. Area of the building (square feet) L 5,;' � �' - 5. Is the building insulated? ®Yes []No 6. How well is the building sealed? aptG i. dumber of elevators in the building. A(h 8. Condition of the elevator pits (sealed, open earth, etc.) LA 9. Above-ground structure construction materials (check all that apply): ZWood ❑Brick ❑Concrete ❑Cement block ®Other jA ,,, c- 10. General description of building construction materials e . 11. Does the building have windows that can be opened? Yes ❑No 11 a. If YES, indicate number and type(s), of window(s): 11 b. If, YES, describe the frequency and duration of window opening: b 12. Does the building have doors? Yes 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 Other [NOTE: If the building does not have a basement,go to question 24.] 14. Basement? ❑Yes, ❑No Crawl Space?,®Yes, ❑No 14a. If YES, under how much of the building floor space? 90 % 15. Is the basement(9finished, 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) 6 Concrete Tile ❑Carpeted 2Dirt GRANIt J(f"X i ❑Wood ❑IOther(describe) ? 17a. If concrete, is the floor ElSealed I+r twO' 0�1"Aay ❑Unsealed ❑Painted EjCovered ❑Cracked ❑Other(piease specify) 18. Are the basement/foundation walls Poured concrete ❑Cement block ❑Stone 17Wood ❑Brick ❑Other ? 19. Are the basement/foundation wails ❑Sealed c-4K"td0 ❑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 time/yr) ENo 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) [OPaint int stripper/remover Paint thinner [EMetal degreaser/cleaner ❑Gasoline ❑Diesel fuel ffIvents ue [].t'aundry spot removers [rain cleaners 10esticides Water and Sewage 24. What is the source of drinking water for the building (check all that apply)? -EPublic 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,12no, []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? ZPublic Sewer ❑Septic ❑Tank ❑Leach Field ❑Other(Specify) 28. What is the distance from the water supply well to septic system (if applicable)? �✓ 9 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: ,gNatural 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 ❑Woad 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) [I]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 /Jllq ❑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) �M ,�► Potential Indoor Sources of Pollution 37. Has the building had termite or other pesticide treatment: ❑Yes RNo ❑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 ONo 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 52No 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 ,RNo 41. Has the building ever had a fire? ❑Yes RNO 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 Z 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 ❑Commercial grade, or [MResidential grade? 45. Is smoking allowed in the building? ❑Yes RN 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,2120 cigarettes per day) 4� Are air fresheners regularly used in the building? ,Ayes Lw--4%m,CUV.,NaImWks ❑No 47. Are any of the following activities performed In the building? E]Heating ❑Soldering OVVeiding [?Painting (brush or roller) F—lPalnfng (spray) N,Vood or metal finishing lather a vlty invoiving chemical usage?(Please describe): .t r fi 48. Please identify building cleaning and maintenance practices: usting ry sweeping Vacuuming ❑Polishing (furniture, etc) EWashing or waxing 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 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 -P< Disinfectants >-C Window cleaners Spray-on oven cleaners Nail polish or remover Hairsprays Solvents/De 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 a'sr 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 � FaiJai 6 Building Address 41? _1d>-f4 .VVoq;f City, State, Zip Code &q.,eyh hj I Field Investigator !f. V_V A%A 9 ZIQ 9- —Date o Field Instrument Used -Pr6d66t.'Dii6rIPtI; P0MM!3.FqW. PAM f. .....Volatile,lngre.dientaln. q...­ uantity. Product, ................f ::�:%Wze'�:rnanu acturer,:'etc.%)" : .. .... btrd f YZU7- Al 6lu flbhV_<4T�� 72-;3, L0014 VL-4VII i" Cd�w daidid Gcenin(t Rob 1— 22-pq V2 ACA PV1Px'0'r%f1 IJ CnA4?. 11-let--54 'A -I L_/5 Chemical Product Inventory Form Building Occupant L) Building Address q-g'eKi City, State, Zip Code &-Lem4p , bA Field Investigator JA A kA S XJL Date----14 0 Field Instrument Used n yka .... ...... . . . ............ P49n ty nber-1 y Produc ot .............Manufa tu ritc 4�Lfck segA3 -1 6 Ida f/vy(f emAtIl --LeAx &-ri kxki 4fihbl'A�;W Rikt,rMy Vew-i Lip, 4 da I I(, dpix-91YV 61 cftJ -j f 11.L / reA"tee PW4 40 q 4 r redjXL dUg±L f/2- JCA R- "X fAA kJt C&2a 11 colw Cut IQ p� ewe tow. PI/AA. �INA4,dS-� 14 fZ' DO 601/'( m r.'Ik'd 444 .00, Chemical Product Inventory Form Building Occupant � � �-m�q-,L4� Building Address City, State, Zip Code ..flzcLo.m A 0 AA Field Investigator SSA U-A fl,F-, Date Field Instrument Used . ............. "'dilln4r-:1 d t4 -h rciaupame ............ ....... A Product giki;manu ad urer - 9'2'VIjkAcaw_ y2t)4t MpAdt; Cu LJ&Pt'� 12- %1 Sp(?,Ai IA' -6A- Lf J 'I"14t aP17AMY1 7- o a, - 1114fiAN 4h:4 wo,4w.ryj aj1pwjv#-( - -?J-j1bo6 Xwtu& 4Mk) &,ft;tko Piz yx /'Y 02- - ,d p wf C-4) fop tiwft Igggr&) A,f il YWA -- Wryt-A" c-60sAA- 'ID 0-4 cAwi CM,/ 144z V-1 L P.,29A-7 Ad/A &M fA1012 4#811A 13'P-t k 4 J— Af. K � ,Cu,,A. a Chemical Product Inventory Form Building Occupant A I a4t rwo r., Building Address City, State, Zip Code fu-Eer-iNvJ , KT- Field Investigator 3 f,tf kg-AiA 2-e it- _Date I&IIA9 Field Instrument Used n P ..........Ca ­M9114iffle Womd1ents uant!W, `:container..."'pppe p ,d . size,:manu acturer:'etc.) I L�L fa-A C-Ar—olit mA44 7o2 - fl Liq4A VAVA 4 fS qn,-,y C ew Auroil C-gri ((,t2kMr 1 15.6 oz vro-V r-qwq roil '8m�t Aurfs C(4"�w j,30?- 0 ,-r1L1g &.11,W I J6Vz Ii t I Q Dr Oil .32-OL / AJe,h,( C1-Q(4j1^ Ot eA&r. Ajoc-c& W44 kA, 'j Z A��J�T' 2r-fdl azL F" § "-Cq A-,Ito- Ya -r l/ F� q AAA / C4'c'i n&,tm/tI F-&ie lale"'- /UF)i Of--aow e. —1 a4' 4 1 14 !!5fCP'1-5 &.0ti—e ( 118PA A�miar- Thks -3, 77 XAaAe 3. 2- o ....................... 19 P-e-, 74 Chemical Product Inventory Form Building Occupant Sly R+ Building Address ------- tit, --3*4 9AVA- City, State, Zip Code 15 0-e i,,/.\%-j Field Investigator- 5-th-ft 14-26 2\,'I- - Date fi - Field Instrument Used M.d.. ti nti -V. ptileIngred en ta them Pia��i .la j NSA- cmfik &J fit, Fovv_ V1- JAJI�N'jj 6I& Ikok 4 S 0, Ali a -w /UX A 0-1k Lan W V /T r oT- 49,n4aid J/vz- #(M!j jr V ("414At"OW Atxd M-piw* 17-0'*- A0 C*Ielj if il-)- A-' e&.-J rq!�A Ad fzT);Tg j Ad ........... ............... Qn, -.--- p vnt 7q f Fe- 1. A : i � I ' l i i I : i e 1� _ zo As .......... I RESIDENTIAL/COMMERCIALIRETAIL QUESTIONNAIRE INDOOR AIR ASSESSMENT SURVEY This form must be completed for each building involved in an indoor air investigation. Preparer's name Sc.�-�t �[-�a4v� +�- Date prepared ra Preparer's affiliation Al C, AS,l U Gi AZ3 Telephone number 2>s" 1 ___ ()-?.j OCCUPANT: Name 114 + j C► ,d Address S`/-1 1) lei City Q0 AIAPI N1� Telephone number What is the best time to call to speak with you? Are you the QOwner, ❑Renter, ❑Other of this Structure? Total number of occupants/persons at this location? Average daily occupant/visitor population: r persons. Number of children? Ages?z_ How long have you occupied this location? Jqal 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?--19 �ears. 3. Number of floors (stories) 4. Area of the building (square feet) b. Is the building insulated? es No 6. How well is the building sealed? 7. Number of eievators in the building 8. Condition of the elevator pits (sealed, open earth, etc.) 9. Above-ground structure construction materials (check all that apply): CRWood [-]Brick Concrete QCement block ❑Other 10. General description of building construction materials 11. Does the building have windows that can be opened? Wes []No 11a. If YEES, indicate number and ype(s) of window(s): 11b. If YES, describe the frequency and duration of window opening: a � 12. Does the building have doors? NYes ❑No 12a. If YES, indicate number and type(s) of door: 3 12b. If YES, d tribe frequency and duration of door opening: eJ CO 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 24.1 14. Basement? Wes, ❑No Crawl Space?'fifes, ❑No 14a. If YES, under how much of the building floor space?ID % 11" 15. Is the basement Winished, 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 ile-- arpeted Dirt [--]Wood ❑Other(describe) ? 17a. If concrete, is the floor ❑Sealed ®,Unsealed ❑Painted ❑Covered ❑Cracked ❑Other(please specify) 18. Are the basement/foundation walls ' oured concrete Cement block ❑Stone ❑VVbod ❑Brick ❑Other ? 19. Are the basement/foundation walls ❑Sealed NkHnsealed 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) ��N es, rarely (less than I timelyr) 0 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 i time/yr) tgNo 22. Does the basement have any of the following? (check all that apply) ❑Floor cracks, ❑Wall cracks ❑Sump RFloor 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) NPaint Npaint stripper/remover d 4, 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)? C&Public water supply TRbottled water 4jq, 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, KNo 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 ❑Sept€c ❑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 ,r!o 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 RForced hot water I-Stearn ❑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? ❑MYes 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? ❑Room fans Ceiling fans ❑Attic fans 34. Is the building ventilated using the fan-only mode of the central HVAC system? ❑Yes NNO 34a. If YES, What is the rated size of the fan? 35. Water Heater Type: KGas ❑Electric ❑Other 36. Water heater location: (please describe) Potential Indoor Sources of Pollution 37. Has the building had termite or other pesticide treatment: Dyes 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 36. Has the building been recently(within the last six months) painted or remodeled? ❑Yes 0 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 Svc 39a. If YES, when and where? 40. Is a dry cleaning service present in the building (check only one box)? ELYes, dry-cleaning performed on-site es, dry-cleaning sent off-site, drop-off only No 41. Has the building ever had a fire? } ❑Yes ,RN0 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? ❑Yes CKNo 43a. Do the hoods vent to the outdoors? ❑Yes Flo 44. Is there an automatic dishwasher? ,X(es ❑No 44a. If YES, is the dishwasher ❑Commercial grade, or residential grade? 45. Is smoking allowed in the building? ❑Yes �4W 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) Q.B. Are air fresheners regularly used in the building? es knto 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: usting CRbry sweeping vacuuming olishing (fur ' tc Washing o axing 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 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 X Insecticides Disinfectants Window cleaners Spray-on oven cleaners Nail polish or remover Hairsprays Solvents/Degreasers Faint 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 o` 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 tieid 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 At"d Gi. 0;,-? Building Address ql-Al V /AV W) I City, State, Zip Code 9vjX4Lk" AA1- Field Investigator rc,/1,q Date Field Instrument Used -01 Vollatille.lingredient%in the,':::: nam ntity.. : ::Product:` container.:41SPR WF-�. P i:.c size, fa c urer, rxe s zo S- Cas caAe AcAm a (aa C-0-A P61J.-tj���a en g-f$W 6W",-14d- /0tv-.1 - (q Vol apld /6 ey;;,L 4.6— et2f ito 9—uw2n elz 9 hV 12. e>o-- OwcrM /0 LVO MV,-reA 61w,Gndl /I /A Kr 22 nZ30 6.-& ',3 9 61- 34 rfr� Colo-+ Chemical Product Inventory Form Building Occupant A644 Gil Building Address City, State, Zip Code AE r Field Investigator C G t- Date 12 —jo Field Instrument Used ..-roducl com MOr'dialh aFh 0;' V ngredienis in Se Q anti. C �container..."::: Produ f", IC:manu ac ureri:e. 1,14M)d &k dr-z pmv I -T) q61- 'b Cute 11 box Czz) 4-Omk PAq Q' 4AP-r &-Ik-A A 516YULQ��fufx�o MA/4 5WAV IdL A, FTkAr WIV q )NIAW -e X-1 2- NV" eAk"4-2-f- -a V" ofzx Ak,r,q! CS-4t4 ow AV of (z) AA 32 Fi1~5 _aq- 6onao 5' - faqo�� P 33 7, -�° 0, 1/v �IA ROYL,Mt-L o( 1_ Of to/ DE gt�v 7/ •� 4r �Lf 3,� s Or�� toIib� y� a1-3 Ate r r'S Orn i Gwlv� LIS sm- wi nJoi^.) cJn6c- GAU, AmridKAa, PUI-Q— toil Nevis 5c r , P-vwv r a-i- Ao Io,s oz Chemical Product Inventory Form Building Occupant of&4AX a4/ l Building Address 61� Y11 " City, State, Zip Code Field Investigator— Lem LLI Date Field,Instrument Used ilk ft6dd6t Ddsdriptild 0 Ingredients in ..,....V latille uantity. uct Yp -d ...................... . . ... manufacturer;etc..:.S ze, f a,4 ccint,— a 10o It-6 12 � 15 /0 3A xlw erz ZO \TOV511 Pax Q- pWVAJ FiAyrl CrprL Cr-Z7 it Chemical Product InventoryForm Building Occupant Building Address City, State, Zip Code Field Investigator ;SV=14W Date - 2 ' 0 Field Instrument Used N Prod uct.Des crl tlo n' .:::.......... u commercial'name ;::;:; :; a :....:: ;'':.::::::::..::: Volatile ingredien:: :,.:..�...(.:::..::.::.:.:::.::::::..:.:::•:: :::..:.:..:....:.�.........:: :. Qntity d� penser type,.container. .. uc size manufacturer ®tc, :::......: ...... . :-..:.:::........... . .. .: . ..... . 2-5 oz S&A,.q A&w s r G 0,o z -jzz haor RnV /� oz.. O �dr� 1� 0L af�'',JU6' �v l �v� /mil i� � �L� o rz, tl� �✓ A 7_ © u�Y per.. r �orkll 'pw-,kre. #Vaf re. � � 6 U�•� wood 't d(er wavA f NJ qrtce dr<vy)"C,, fw,4 yvi &, r U3094 I 1 �, rd tAJ ke-(oh (C._4 -q-102 ACC, toi(e t &6j( & 2-4 OL . sn>�� a(r pwrrDs-e. e(ejvt- �zoVim, �I-X �ei%%L- 0/4 1 G,A1 q w�rcyc(, vil 3 ..3 z. 71 K; yhr.A 4'a.¢.1 'c,G.V' �/7 f1 Z. C kdv, h fJ X f AlV(pr Va(rr6j,,ha Av.4-or ad t14. 3J N��EG�1� j,.�.Ftic!?G6�. �6.�.t►�lLt•,/I .Z()'^�"JrU !/ l��`1 D1hd�w. j7sv4r)W .SRC .Zo u-rO L.: &t If-,644;1` /Z, .............. i I i 7 1 ( i ( i j .. .. ........... 7Q .................. . .......... RESIDENTIAUCOF.I.,)AERCIAURETAIL QUESTIONNAIRE INDOOR AIR ASSESSMENT SURVEY This form must be qcwppleted for Tach building involved in an indoor air investigation. Date prepared Preparees.name f Preparers affiliation- Telephonenumber w I N, OCCUPANT: Name . Address co Telephone number What is the best time to call to speak with you? Are you the D-Owner, ORenter, []Other of this Structure? Total number of occupants/persons at this location? Average daily occupant(visitor population persons. Number of children?_Ages? Now long have you occupied this location? OWNER OR LANDLORD: Name (if different from occupant) AddresWI" Telephone number Land Use and Building Construction 1. Type(Check appropriate responses): []Residential ornmercial EX i Jofflce ^..]Warehouse !.]strip hail 2. Age of the building? years. P 3. Number of floors(stories), ' 4.. .Area of the building(square feet) 5. is the building insulated? fhj(�i� EjNo 9. How well is the budding sealed? I 7. Number of elevators in the building 1 S. Condition of the elevator pits(sealed, open earth, etc.) �4 9. Abov"round structure construction materials (check,all that apply): .Mod _..iBrick J9on+ to �-;Cement block 714ther � r 10 General deacipptiop of builong construction materials 11. Does the building have windows that can be opened? No 11a. If YES, indwate number and type(s)of window(s): 1 11 b. If YES, describe the frequency and duration of window opening i 12. Boss the building have doors? r�-a.. Ycss No 1. a.ifYES, iVicatir' mber,and type(s) of I 12b., If'iES, describe frequency and duration of door opening-. 13, Foundation Construction (check all that apply): K(Concrete slab on grade Concrete ®Concrete block []Elevated above ground/grade []Full Basement []Crawispac e []Other,,., V.0TE: if the building does not have a basement, go to question 24.1 14. Basement's []Yes,nNo Crawl Space?❑Yes. l ;No 14a. if YES, under how much of the building floor space? % 15. Is the basement Ejtinished, or F 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) Q� i0oncrete :Nile ILtarpeted EIDIrt E:.-Wood F--jOther(describe).- ? 17a. It concrete. is the floor [---Seated EUnsealed r;Painted ;Covered I �Cracked 000m(please specify)_ 18. Are the basement/fbund.ation walls —1voured concrete Cement block LjStone :1:IVYbod 13Ekick Dother ? 19. Are the basement/lbundation walls ElSealed 'r—Unsealed LIUnknown 20. Does the basement have a moisture or water infiltration problem(check one only)? -Yes,.frequently (3 or more timesNr) [-]Yes. occasionally(1-2 firneWyf) ; ?Y es, rarely(less than I timelyr) ONO 21. Does the basement ever flood(check one only)*) 7 jYes, frequently(3 or more timeslyr) IYes, occasionally (1-2 bnvWyr) OYes, rarely (Wes then I ihmetyr) FINo 22. Data the basement have any of the following?(check all that apply) I �Floar Ct"d , Wall cracks —Sump `,�'Floor drain ,ether hole/opening in floor (describe) (Identify all potential sail gas entry points and their size`. (e.g., cracks, voids, pipes, utility parts, sumps, drain boles, etc.), and any fluid accumulated. 23. Are any of the following used or stared in the basement(check all that apply) ,]Paint ]Paint stripperfremover FlPaint thinner DMetal degreaseddeaner -?Gasoline Diesel fuel Solvents Glue ,,Itaundry spot removers ❑Drain cleaners []Pesticides Water and Sewage 24. t is the source of drinking water for the building (check all that apply)? R, Public water supply 118ottled 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 Dther, please specify 23 Are there taste andtor actor problems with the water supply? ElYes,�No If YES, please describe Now long has the taste and/or odor problem been present? r 1 24. Is the viater chlorinated, biominated, or ozonated� ly ,F]no, []unknown 25. Does the building have a private well for purposes other than drinking? I Yes If YES, please describe purpose of the well: 26. Does the building have a septic system? Yes T77140 Not used (Unknown 27, How is sewage disposed? '`ditblic Sewer septic nTank "Leach Field Other(Specify.) 28. i t is the distance from the water supply well to septic system (if applicable)? j i i fl- r feet 29a.Are septic tank additives used? 'Yes MNo 7;Unknown. If so,what type? 29. Is there standing water outside the building (pond, ditch,swale)? `C Yes `.JNo Heating, Ventilation, and Air Conditioning 30, Heating system fuel or power supply? Check all that apply- h Natural Gas 711-leating Oil ❑Gas LAI Electric MOther 38. Water heater location, (please describe) ,- �, ��" A"�,3✓�,"�, -1 3°-5'%� Potential Indoor Sources of Pollution 37. Has the building had termite or other pesticide treatment: « Yes No DUnknown 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? Dyes "ONO 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 7iqo 39a.. if YES,when and where? 40. is a dry cleaning service present in the building (check only one box)? E] es, dry-cleaning performed can-site QYes. dry-cleaning sent off-site, drop-off only 2lo 41. Has the building ever had a fire?