Board of Health Ice Rink Inspection Sheet
  
Date of Inspection: __________Inspection Conducted by:___________________________  
  
Rink Information 
Name of Rink: _____________________________________________________ 
Street:____________________________________________________________ 
City: __________________________________________State: MA 
Zip Code: __________________________ 
Contact: __________________________________________________________ 
Telephone Number: ___________________ Fax Number: ________________________ 

Record Keeping Log 
  
Is a Record Keeping Log kept by the rink?          	Y  	N 
  
Is the following information kept in this log? (Circle Y for yes, N for No or enter information) 
  
Ice Resurfacing Equipment 

	Brand of ice resurfacer       	Y 	N

	Age of resurfacer        	Y 	N 

	Fuel type:         	Gasoline    Propane  
                    	Natural Gas 
	Dates of tuning:        	Y 	N 

	Name, company and address of person  
 	performing the tuning       	Y 	N 

	Name, company and address of person  
  	performing repairs of maintenance 
 	on the ice resurfacer       	Y 	N 

	Manufacturer, type and date of installation 
 	of a catalytic converter      	Y 	N 

	Name, company and address of person installing 
	or performing maintenance of the catalytic converter      	Y  	N

Air Sampling Information 

Date, location and time of every sample  
of carbon monoxide or nitrogen dioxide          	Y  	N 

Results of air sampling in parts per 
million (ppm) for carbon monoxide and 
nitrogen dioxide        	Y 	N 

Name of sampling devices       	Y 	N 

Method for sampling carbon monoxide        	colorimetric 
         	hand-held monitor 
                  	in place chemical  
                        	sensor  
                  	computer chip 

Method for sampling carbon monoxide        	colorimetric 
                  	computer chip 

Signature of person performing the air sampling        	Y  	N 

Description of correction measures taken 
for air levels above correction levels            	Y  	N 

Results of carbon monoxide and nitrogen 
dioxide after correction measure 
implemented                 	Y 	N 

Date of last calibration and name of person 
performing the calibration       	Y 	N 

Lot numbers of colorimetric tubes or computer 
chip sampling devices       	 Y 	N 

Resurfacer Schedule 
  
Number of resurfacing prior to inspection, that day? _________ 

Number of resurfacings per day: 

Mon___ 	Tues___ 	Wed___ 	Thur___ 	Fri___ 	Sat___ 	Sun___

Type of Ventilation 
  
Supply   	On 	Off 	Capacity (CFM)________________ 
Exhaust   	On 	Off 	Capacity (CFM)________________ 

Size of Rink 
  
Square feet: _____________        	Ceiling height: ___________  

Indoor Air Test Results for Skating Rinks  

Sample	Date	Time	Carbon Monoxide  
* ppm  
	Nitrogen Dioxide 
* ppm  
	Air Sample 
Device  
	Remarks  
	
Outside 
Ambient Air  							
20 Minutes 
After Resurface  							
40 Minutes 
After Resurface  							
60 Minutes 
After Resurface							
Immediately After 
Resurface  							
20 Minutes 
After Resurface  							
40 Minutes 
After Resurface  							
60 Minutes 
After Resurface  							
*ppm = parts per million of air 

Indoor Air Levels for Carbon Monoxide and Nitrogen Dioxide 

If an air sample exceeds 30 ppm for carbon monoxide or 0.5 ppm for nitrogen dioxide, the rink must take 
positive measures to decrease air concentrations of these contaminants below these standards. 

If an air sample exceeds 60 ppm for carbon monoxide or 1 ppm for nitrogen dioxide, the rink must notify the 
local fire department, local board of health and the Bureau of Environmental Health Assessment within 24 hours 
of  sampling.

If an air sample exceeds 125 ppm for carbon monoxide or 2 ppm for nitrogen dioxide, EVACUATE THE 
RINK, notify the local fire department, local board of health and the Bureau of Environmental Health 
Assessment. 

The Bureau of Environmental Health Assessment can be contacted at (617) 624-5757 during work hours, or at 
(617) 522-3700 during the night or weekend. 

Form:ice4/(amended 2000)