Lichen Technology, Inc. 

AIR QUALITY EVALUATION FORM #1

 SIDE A
Twig number  1 2 3 4 5 6 7 8 9 10
Twig age                     
Evernia prunastri                     
Hypogymnia physodes                    
Hypogymnia tubulosa                    
Lecanora carpinea                    
Lecanora confusa                    
Lecanora pacifica                    
Lepraria candelaris                    
Lepraria membranacea                    
Lobaria pulmonaria                    
Parmelia sulcata                    
Physcia adscendens                    
Physcia aipolia                    
Platismatia glauca                    
Ramalina farinacea                    
Ramalina menziesii                    
Rinodina archaea                    
Rinodina marysvillensis                    
Usnea subfloridana                    
Xanthoria polycarpa                    

Use the following code
to record % cover:

5 = barely present to 5%
25 = 5% to 25%
50 = 25% to 50%
75 = 50% to 75%
95 = 75% to 95%
100 = 95% to 100%

 Copyright 1973 by Lichen Technology, Inc.
Box 369, Corvallis, OR 97330

SIDE B

Person or group taking sample:
Name: ________________________
Address: _____________________________________________________________

I. Location of Sample Site

   A. State: ________________

   B. County: __________________

   C. UTM Military Grid Coordinates: East: ________ km    North: ________ km

   D. Urban Sites: Street address: ________________________________________

   E. Rural Sites:
            1. Nearest city or town:
                    a. Name: _______________
                    b. Distance: ____________
                    c. Direction: ____________
            2. Nearest road:
                    a. Name: _______________
                    b. Distance: ____________
                    c. Direction: ____________

   F. Landmarks: ______________________________________________________
        ________________________________________________________________

   G. Specific directions: ________________________________________________
        ________________________________________________________________

II. Description of Sample Site

   A. Sample Tree
            1. Species of tree: ____________
            2. Height of tree: _____________
            3. Diameter of trunk 4.5 feet above ground: ____________
            4. Position: (check one)
                        a. standing alone
                        b. at the edge of the woods
                        c. one of a small clump of trees in the open
                        d. in a line of trees along a road, stream, etc.
                        e. other: (describe) _______________________________________
                                    ___________________________________________________
                                    ___________________________________________________

   B. Land Use Pattern in Sample Area: (check one or more)
            1. residential
            2. industrial
            3. agricultural
            4. other: (describe) _____________________________________________
                        _________________________________________________________
                        _________________________________________________________

   C. Altitude: (check one)
            1. 0 - 500 ft.
            2. 500 - 1000 ft.
            3. above 1000 ft.

   D. Slope
            1. Degree: (check one)
                        a. level (less than 10º from horizontal)
                        b. moderate (10º - 40º)
                        c. steep (more than 40º)
            2. Direction downslope from sample tree: ________________________