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Appendix D https://www.pca.state.mn.us • 651-296-6300 • 800-657-3864 • Use your preferred relay service • Available in alternative formats c-rem3-01a • 1/13/21 Page 1 of 8 Vapor intrusion building survey form Remediation Division Doc Type: Site Inspection Information Instructions: Complete the vapor intrusion building survey form to document general building characteristics, points where soil gas may enter the building, and identify potential indoor contaminant sources. Preparer’s name: Zachary Ford Date (mm/dd/yyyy): 8/27/2024 Affiliation: Stantec Consulting Services Inc. Time prepared: 10:30 am pm Email: zachary.ford@stantec.com Phone number: 651-294-4590 Part 1: Property owner and building occupant information 1. Owner/Landlord information Individual or corporate name: Tibyan Community Center Interviewed? Yes No Mailing address: 2500 Minnehaha Avenue South City: Minneapolis State: MN Zip code: 55404 Phone: Email: Alternative contact name (if any): Phone: 2. Occupant information (Check if same as owner: ) Occupant name(s): No current occupants Interviewed? Yes No Mailing address: City: State: Zip code: Phone: Email: Number of occupants at this location: Age range of occupants: Part 2: Building evaluation 3. Building use (Check appropriate response) Residential Child/Day Care School Church Hospital Long-term care facility Correctional facility Commercial Industrial Other (specify): Vacant If the property is residential, what type? (Check appropriate response) Ranch rambler Raised rambler Townhouses/Condos Duplex Modular 2-Family Split level Contemporary Apartment house Cape cod Log home 3-Family Colonial Mobile home Other (specify): 4. Building description If the property is commercial or industrial, describe the business use(s): Indicate the number of floors and general use of each floor of the building beginning with lowest level: Basement level: Vacant space Main level: Vacant space Second level: Vacant space 80