6000-016 Soil Gas Safe Communities Building Survey - Indoor Air S

OMB Control Number: 2080-0083; Expiration Date: 01/31/2024

OMB Instrument Form for Generic Citizen Science ICRs
Burden Statement:
This collection of information is approved by OMB under the Paperwork Reduction Act, 44 U.S.C. 3501
et seq. (OMB Control No. 2080-0083). Responses to this collection of information are voluntary under
the National Contingency Plan (NCP) § 300.415 (a) (n) (3) (i). An agency may not conduct or sponsor,
and a person is not required to respond to, a collection of information unless it displays a currently valid
OMB control number. The public reporting and record keeping burden for this collection of information
is estimated to range up to 45 minutes per response. Send comments on the Agency’s need for this
information, the accuracy of the provided burden estimates and any suggested methods for minimizing
respondent burden to the Regulatory Support Division Director, U.S. Environmental Protection Agency
(2821T), 1200 Pennsylvania Ave., NW, Washington, D.C. 20460. Include the OMB control number in any
correspondence. Do not send the completed form to this address.

EPA Form #: 6000-016

OMB Control Number: 2080-0083; Expiration Date: 01/31/2024

Soil Gas Safe Communities
Building Survey - Indoor Air Sampling
Project Information

Page 1 of 7

Project Name:

Site Name:

Survey Completed By:

Date:

Building Address:

Residence ID:

Resident and Contact Information
Name of Occupant:

Owner / Tenant / Other:

Name of Interviewee for Building Survey (if different from above):
Occupant Phone #s:

Home:

Cell:

Duration at Current Residence:

Best Time To Call / Visit:

Number of Building Occupants:

Children (list ages):

Adults:

(If Rental) Property Owner Name:

Cell or Home #:

Owner Address:

Work #:
Do you have a dog, cat, or other pet we need to be aware of while inside the house? :

Yes / No

If yes, is the animal friendly (e.g., won't try to bite):

Yes / No

Do you have a security system that needs needs to be disarmed before we enter a portion of the house?:

Yes / No

Notes:
Awareness of Subsurface Contamination
Is anyone in your household familiar with environmental cleanup in general or vapor intrusion?

Yes / No

Are you or anyone else in your household familiar with subsurface contamination in the area?

Yes / No

If yes, were you aware of the contamination when you moved in or purchased the property?

Yes / No

Has anyone in your household interacted with consultants or officials engaged in the environmental response for
contamination in your area?

Yes / No

Has anyone in your household ever attended a meeting about environmental contamination or cleanup in your area?

Yes / No

Is there someone or an organization that you trust to provide you with reliable information about addressing
site contamination?

Yes / No

If yes, are you willing to share the name of the organization:
Building Construction Characteristics
Building Type: (Check box for all that apply)
Single Family Residential

Ranch

Split Level

Duplex (# of other half of duplex):

Multi Family Residential

Two-story

Tri Level

Apartment (# of units in Building):

Commercial / Multi-use

Other (specify):

Describe Building: (General Description, Construction Materials, etc.)

Approximate Age:
Floors:

years

Approximate Area:

Total Living Space:

# Floors at or above grade:
Which floors of the residence are utilized as living space / occupied?

Foundation Type:

Foundation Description: (Split Foundation or Multiple Types)

Crawl Space:

Yes / No

Slab on Grade:

Yes / No

Basement:

Yes / No

EPA Form #: 6000-016

Slab & Crawl Space Construction:

sq.ft.

First Floor:

sq.ft.

OMB Control Number: 2080-0083; Expiration Date: 01/31/2024
Building Survey

Page 2 of 7
Date:

Residence ID
Basement or Crawl Space Details: (if applicable)
Finished Basement:

Yes / No

Basement Finished When:

Approximate Area:

sq.ft.

Basement or Crawl Space Floor: (Check box for all that apply)
Concrete

Floating (built on
top of actual floor)

Dirt

Other (specify):

Foundation Walls: (Check box for all that apply)
Poured Concrete

Block

Stone

Other (specify):

Does the basement or crawl space have a moisture problem - dampness? (Check only one)
Yes, frequently
(3 or more times/year)

Yes, occasionally
(1-2 times/year)

Yes, rarely
(less than 1 time/year)

No

Yes, rarely
(less than 1 time/year)

No

Is the basement or crawl space ever wet - flooded? (Check only one)
Yes, frequently
(3 or more times/year)

Yes, occasionally
(1-2 times/year)

Basement or Crawl Space Details Continued: (if applicable)
Does the basement have any of the following? (Check all that apply)
Floor cracks

Wall cracks

Floor Drain

Sump pump

Other hole / opening in floor (describe):
Is the sump pump used?

Yes / No

Depth of sump?

ft

Where does the sump pump drain?

Describe ventilation of crawl space:

Description of ground cover outside of building:

Grass

Concrete

Asphalt

Other:

Heating, Ventilation, and Air Conditioning Systems
Heating System - Fuel Type: (Check box for all that apply)
Natural Gas

Electric

Wood

Other (specify):

Coal

Fuel Oil

Heating - Conveyance System: (Check box for all that apply)
Forced Hot Air

Electric Baseboard

Wood Stove

Fireplace

Forced Hot Water

Hot Water Radiation

Heat Pump

Kerosene Heater

Bathroom ventilation fans

Air-to-air heat exchanger

Other (specify):
Type of Ventilation System: (Check box for all that apply)
Central air handler / blower

Mechanical / ceiling fans

Kitchen range hood fan

Other (specify):

Does the Residence have Air Conditioning: (Check box for all that apply)
Central Air Conditioning

Window Air Conditioners

Describe the current operating conditions of the HVAC system:

EPA Form #: 6000-016

Other (specify):

OMB Control Number: 2080-0083; Expiration Date: 01/31/2024
Building Survey

Page 3 of 7
Date:

Residence ID
Miscellaneous Information
Does the Residence have any of the following?
Septic System?

Yes / Yes (but not used) / No

Irrigation / Private Well?

Existing subsurface depressurization (radon) system in place?

Yes / No

Standing water outside the residence (pond, ditch, swale)?

Yes / No

If yes, describe (with location):

Yes / No

If yes, describe (with location):

Is there a pet door to the exterior?

Is it running?

Yes / No

Has the residence been retrofitted / weatherized with any of the following? (Check box for all that apply)
Insulation

Storm Windows

Does the building have an attached garage?

Energy-efficient windows
Yes / No

Other (specify):

If yes, is a car usually parked in the garage?

Yes / No

Chemicals
Yes / No

Have any pesticides / herbicides been applied around the building foundation or in the yard / gardens?
If yes, when - and which chemicals?
Has the residence had a pesticide treatment inside?

Yes / No

When / by whom?

Do any occupants have their clothes dry-cleaned?

Yes / No

When were dry-cleaned clothes last brought into the building?

Have the occupants ever noticed any unusual odors in the buidling?

Yes / No

If yes, describe (with location):
Yes / No

Have there been any known spills of a chemical immediately outside or inside the building?
Describe (with location):
Do any of the occupants smoke inside the building?

Yes / No

How often?

Do any of the occupants use solvents at work?

Yes / No

Are their clothes washed at home?

Yes / No

If so, when - and what rooms?
Within the last 6 months, has there been any painting or remodeling in the residence?

Yes / No

If yes, when

What rooms, and what specifically was done?
Do you plan to remodel your home or repaint the interior within the next year?
Within the last 6 months, has any new carpeting been installed?
If so, when, what rooms, and what type of cleaners?

EPA Form #: 6000-016

Yes / No

Yes / No

If yes, when

Have the carpets or rugs been cleaned?

Yes / No

OMB Control Number: 2080-0083; Expiration Date: 01/31/2024
Building Survey

Page 4 of 7
Date:

Residence ID

Consumer Products Inventory
Check consumer products that are present in the residence.
Storage Location
Paint or Wood Finishes (spray or can)
Paint stripper / remover / thinner
Solvent cleaners (eg. spray-on oven cleaner)
Metal degreaser / cleaner
Gasoline / diesel fuel
Glues or adhesives (super glue, etc)
Air fresheners & scented candles
Laundry / carpet spot removers
Pesticides / Insecticides
Nail polish remover (acetone)
Aerosols (deodorizers, polish, cleaners)
Other:
Other:
Other:
Describe any products that are containerized during sampling event:

Provide any additional information that is provided by interviewee:

EPA Form #: 6000-016

Frequency of Usage

Date of Last Use

OMB Control Number: 2080-0083; Expiration Date: 01/31/2024
Building Survey
Residence ID

Page 5 of 7
Date:

Building Sketch
Provide sketch of floors in house, including the following information:
Street (sidewalk, patios, driveway, distance to house)
Location of heating and cooling systems, including fireplace
General location of doors and windows (including exterior pet doors)
Exterior / Street

First Floor (or Main Living Floor)

Basement/Crawlspace

Other

EPA Form #: 6000-016

Primary chemical storage location(s)
General orientation of garage and main rooms

N

OMB Control Number: 2080-0083; Expiration Date: 01/31/2024

Post Sampling Review

Page 6 of 7

Residence ID
Sampling Revisit #:

Complete for each Post Sampling Visit
Date:

Sampling Team:

Has any information changed since the beginning of the last sampling event?
Did windows and doors remain closed?
Was any dry cleaning brought home?

Yes / No

If yes, in which rooms:

Yes / No

Did you do anything unusual in terms of cleaning, painting, or renovating your home in the past week?
Were any of the consumer products discussed earlier this week used in the last 24-hours?

Yes / No

If yes, which products:

Notes / other information observed post-sampling:

Sampling Revisit #:

Date:

Sampling Team:

Has any information changed since the beginning of the last sampling event?
Did windows and doors remain closed?
Was any dry cleaning brought home?

Yes / No

If yes, in which rooms:

Yes / No

Did you do anything unusual in terms of cleaning, painting, or renovating your home in the past week?
Were any of the consumer products discussed earlier this week used in the last 24-hours?

Yes / No

If yes, which products:

Notes / other information observed post-sampling:

Sampling Revisit #:

Date:

Sampling Team:

Has any information changed since the beginning of the last sampling event?
Did windows and doors remain closed?
Was any dry cleaning brought home?

Yes / No

If yes, in which rooms:

Yes / No

Did you do anything unusual in terms of cleaning, painting, or renovating your home in the past week?
Were any of the consumer products discussed earlier this week used in the last 24-hours?

Yes / No

If yes, which products:

Notes / other information observed post-sampling:

Sampling Revisit #:

Date:

Sampling Team:

Has any information changed since the beginning of the last sampling event?
Did windows and doors remain closed?
Was any dry cleaning brought home?

Yes / No

If yes, in which rooms:

Yes / No

Did you do anything unusual in terms of cleaning, painting, or renovating your home in the past week?
Were any of the consumer products discussed earlier this week used in the last 24-hours?
Notes / other information observed post-sampling:

EPA Form #: 6000-016

Yes / No

If yes, which products:

OMB Control Number: 2080-0083; Expiration Date: 01/31/2024
Post Sampling Review Continued

Page 7 of 7

Residence ID
Sampling Revisit #:

Complete for each Post Sampling Visit
Date:

Sampling Team:

Has any information changed since the beginning of the last sampling event?
Did windows and doors remain closed?
Was any dry cleaning brought home?

Yes / No

If yes, in which rooms:

Yes / No

Did you do anything unusual in terms of cleaning, painting, or renovating your home in the past week?
Were any of the consumer products discussed earlier this week used in the last 24-hours?

Yes / No

If yes, which products:

Notes / other information observed post-sampling:

Sampling Revisit #:

Date:

Sampling Team:

Has any information changed since the beginning of the last sampling event?
Did windows and doors remain closed?
Was any dry cleaning brought home?

Yes / No

If yes, in which rooms:

Yes / No

Did you do anything unusual in terms of cleaning, painting, or renovating your home in the past week?
Were any of the consumer products discussed earlier this week used in the last 24-hours?

Yes / No

If yes, which products:

Notes / other information observed post-sampling:

Sampling Revisit #:

Date:

Sampling Team:

Has any information changed since the beginning of the last sampling event?
Did windows and doors remain closed?
Was any dry cleaning brought home?

Yes / No

If yes, in which rooms:

Yes / No

Did you do anything unusual in terms of cleaning, painting, or renovating your home in the past week?
Were any of the consumer products discussed earlier this week used in the last 24-hours?

Yes / No

If yes, which products:

Notes / other information observed post-sampling:

Sampling Revisit #:

Date:

Sampling Team:

Has any information changed since the beginning of the last sampling event?
Did windows and doors remain closed?
Was any dry cleaning brought home?

Yes / No

If yes, in which rooms:

Yes / No

Did you do anything unusual in terms of cleaning, painting, or renovating your home in the past week?
Were any of the consumer products discussed earlier this week used in the last 24-hours?

Yes / No

If yes, which products:

Notes / other information observed post-sampling:

Sampling Revisit #:

Date:

Sampling Team:

Has any information changed since the beginning of the last sampling event?
Did windows and doors remain closed?
Was any dry cleaning brought home?

Yes / No

If yes, in which rooms:

Yes / No

Did you do anything unusual in terms of cleaning, painting, or renovating your home in the past week?
Were any of the consumer products discussed earlier this week used in the last 24-hours?

EPA Form #: 6000-016

Yes / No

If yes, which products:

OMB Control Number: 2080-0083; Expiration Date: 01/31/2024
Notes / other information observed post-sampling:

EPA Form #: 6000-016