(c: )
Block: Residential 0 Commercial D Name of Building:
Lot: Mix Use 0 Other
# of Stories: AKA's:
Building Owner/Management: Telephone Number: ( )
Name: FAX:
Address:
On Site Contact:
Name: ' - .. . Telephone Number:
Building Owner Management Activities
Interior Survey Performed ❑ Yes ❑ No
Exterior Survey Performed ❑ Yes ❑ No
General Clean Up ❑ Yes ❑ No Locations:
ACM Clean Up ❑ Yes ❑ No Locations:
Air Monitoring ❑ Yes ❑ No Locations:
Copies of All Reports and Data Requested Yes
Visual Inspection Results:
Facade:
Inspected Debris
North ❑ N/A Yes ❑ No gNo Visible/Fine Layer 934 to 1" ❑ >V
South
East
West
RNIAN/A
-N/A
[Yes ❑ No
❑ Yes ❑
D Yes ❑ No
No ❑ No Visible/Fine Layer
❑ No Visible/Fine Layer
❑ No Visible/Fine Layer
❑ i,4 to V
❑ % to 1'
❑ % to 1"
❑ >1"
❑ > 1"
❑ > 1'
Facade Description: