WTC Visual Survey Form
Premise Address: ~
t% K
Block: Residential Commercial Name of Building:
Lot: Mix UseD 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 J J Yes
Visual Inspection Results:
Facade:
Inspected Debris
North ❑ NIA ❑Yes ❑ No ❑ No Visible/Fine Layer ❑ 4to1" 0>1"
South ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑%to1" 0>1"
East ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑ % to 1" 0>"'
West ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑%to1" 0>1"
Facade Description:
.,S of
Roof
,
Debris: No Visible /Fine ayer ❑ % to 1" •1 fJ> 1"
Description: _ _ IG wrn.tJ4 P - ' - c- c~ C Cro
Setbacks N/A
Floor: Debris: ❑ No Visible/Fine Layer ❑'h to 1"
Floor: Debris: ❑ No Visible/Fine Layer ❑ % to 1"
Floor: Debris: ❑ No Visible/Fine Layer ❑ %: to 1"
Floor: Debris: ❑ No Visible/Fine Layer ❑'/z to 1"
Floor. Debris: ❑ No Visible/Fine Layer ❑ %: to 1"