Block: Residential Commercial Name of Building:
Lot: Mix Use ❑ 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 0 No ❑ No Visible/Fine Layer ❑ Y2 to 1" ❑ > 1"
South ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑ Y2 to 1" ❑ > 1"
East ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑ Y2 to 1" ❑ > 1"
West ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑ Y2 to 1" ❑> 1
Facade Description: ,
k C
Roof
Debris: ❑ No Visible /Fine tayer ❑ 1/ to 1" •1 ='i'"' A ❑ > 1" 1
Description:
Setbacks N/A ❑
Floor: Debris: ❑ No Visible/Fine Layer ❑'/2 to 1" ❑ > 1"
Floor: Debris: ❑ No Visible/Fine Layer ❑'/ to 1" ❑ > 1"
Floor: Debris: ❑ No Visible/Fine Layer ❑ Y2 to 1" 0> 1"
Floor: Debris: ❑ No Visible/Fine Layer ❑'/ to 1" ❑ > 1"
Floor: Debris: ❑ No Visible/Fine Layer ❑'/ to 1" ❑ > 1"