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State of California October 2011 Vapor Intrusion Guidance Document—Final DTSC—Cal/EPA APPENDIX L - BUILDING SURVEY FORM Preparer's Name: Date/Time Prepared: Affiliation: Phone Number: Occupant Information Occupant Name: Interviewed: ❑ Yes No Mailing Address: City: State: Zip Code: Phone: Email: Owner/Landlord Information (Check if same as occupant ❑) Occupant Name: Interviewed: 0 Yes No Mailing Address: City: State: Zip Code: Phone: Email: Building Type (Check appropriate boxes) ❑ Residential ❑ Residential Duplex ❑ Apartment Building ❑ Mobile Home ❑ Commercial (office) ❑ Commercial (warehouse) ❑ Industrial ❑ Strip Mall ❑ Split Level ❑ Church ❑ School Building Characteristics Approximate Building Age (years): Number of Stories: Approximate Building Area (square feet): Number of Elevators: Foundation Type (Check appropriate boxes) ❑ Slab-on-Grade ❑ Crawl Space ❑ Basement Basement Characteristics (Check appropriate boxes) ❑ Dirt Floor ❑ Sealed ❑ Wet Surfaces ❑ Sump Pump ❑ Concrete Cracks ❑ Floor Drains Factors Influencing Indoor Air Quality Is there an attached garage? ❑ Yes No Is there smoking in the building? Yes 0 No Is there new carpet or furniture? Yes IN No Describe: Have clothes or drapes been recently dry cleaned? Yes No Describe: Has painting or staining been done with the last six months? Yes No Describe: Has the building been recently remodeled? 0 Yes No Describe: Has the building ever had a fire? Yes N No Is there a hobby or craft area in the building? Yes 011111111 No Describe: Is gun cleaner stored in the building? 0 Yes 011111111 No Is there a fuel oil tank on the property? 0 Yes M No Is there a septic tank on the property? 0 Yes ❑ No Has the building been fumigated or sprayed for pests recently? Yes No Describe: Do any building occupants use solvents at work? p Yes No Describe: L- 1