New Jersey Department of Health

Consumer, Environmental and Occupational Health Service

Environmental and Occupational Health Assessment Program

PO Box 369, Trenton, NJ 08625-0369

Child Care Center - Indoor Environmental Health Assessment

Form F: HAZARDOUS SUBSTANCES AND VAPOR INTRUSION

Facility Name

Street Address

City

County

Directions: Provide the following information. Check whether the substance was or is currently present and where it is (or was) located.

I. Hazardous Substances that are Currently or were Formerly Present
Substance	Currently

Present (()	Formerly Present (()	Location	Condition
Asbestos

(Surfacing, Thermal Insulation, Exterior Roofing/Siding, etc.)
Organic Compounds
Formaldehyde
Inorganic Compounds
Pesticides
Radon
Lead Based Paint
Mold
Volatile Organic Compounds

II. Additional Metals (other than lead) that are Currently or were Formerly Present. (Use an additional sheet, if necessary.)
Additional Metals (list below)	Currently

Present (()	Formerly Present (()	Location	Condition

III. Additional Hazardous Substances (not previously indicated) that are Currently or were Formerly Present. (Use an additional sheet, if necessary.)
Substance	Currently

Present (()	Formerly Present (()	Location	Condition

IV. Vapor Intrusion Potential
Is there a potential for Vapor Intrusion? No Yes

If yes, you MUST include a site diagram indicating source and area of concern, and complete the following (use additional sheet if necessary):
Chemical

Describe Source(s)

Chemical

Describe Source(s)

V. Underground Storage Tank
Is there an underground storage tank present on the property? No Yes

If yes, you MUST include a site diagram indicating source and complete the following:
Tank Size

Chemical

Condition

Location

Child Care Center - Indoor Environmental Health Assessment

Form F: hazardous substances and vapor intrusion

(Continued)

CEHS-6

AUG 12	Page 2 of 2 Pages.

AUG 12	Page 1 of 2 Pages.

CEHS-6, Form F: Hazardous Substances and Vapor Intrusion

CEHS-6, form f, hazardous substances, vapor intrusion, indoor environmental health assessment, child care center

ewhite

2012-03-20

NJDOH