rernlise Address:
--7O ma;.JQ t--e2 Q
Block: Residential D Commercial JJ Name of Building:
Lot: Mix UseD Other
# of Stories: AKA's:
Building Owner/Management: Telephone Number. ( )
Name: FAX:
Address:
On Site Contact
Name: 0 Telephone Number.
Building Owner Management Activities
Interior Survey Performed ❑ Yes ❑ No
Exterior Survey Performed ❑ Yes ❑ No
General Clean Up BYes ❑ No Locations:
ACM Clean Up DYes[] No Locations:
Air Monitoring JYes ❑ No Locations:
Copies of All Reports and Data Requested J Yes
Visual Inspection Kesults:
Facade:
Inspected Debris
North ❑ N/A Yes ❑ No o Visible/Fine Layer ❑'/to1" ❑>1"
,South N/A Yes ❑ No No Visible/Fine Layer ❑%to1" 0>1"
East J N/A D Yes ❑ No ❑ No Visible/Fine Layer ❑%to 1" 0>1"
West N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑%to1" ❑>1"
Facade Description:
Roof
Debris: ❑%to1" 0>1"
Description:
Setbacks N/A ❑
.Floor: Debris: ❑ No Visible/Fine Layer ❑ Y2 to 1" ❑ > 1"
Floor. Debris: ❑ No Visible/Fine Layer ❑ % to? ❑ > 1"
Floor: Debris: ❑ No Visible/Fine Layer ❑ Va to 1" ❑ > 1"
Floor. Debris: ❑ No Visible/Fine Layer ❑ Va to 1" ❑ > 1"
Floor. Debris: ❑ No Visible/Fine Layer ❑ Va to 1" ❑ > 1"