Block: Residential 0 Commercial Name of Building:
Lot: Mix Use J Other .
# of Stories: 3 AKA's: E'T
Building Owner/Management: Telephone Num (Yl -) L -- c
Name: r `'~ -~ v~< < L FAX:
Address:
On Site Contact:
Name: k — Telephone Number: (Yt2) ( S_
Building Owner Management Activities
Interior Survey Performed ❑ No
Exterior Survey Performed [Yes Yes ❑ No •
General Clean Up es ❑ No Locations: ~~\F '~~
ACM Clean Up Yes ❑ No Locations:
Air Monitoring - -Yes ❑ No Locations:
Copies of All Reports and Data Reguested,jYes
Visual Inspection Results:
Facade:
Inspected Debris
North /A ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑ to 1"
'/2 ❑ > 1"
South /A ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑'/2 to 1" ❑ > 1"
East N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑'/2 to 1" ❑ > 1"
West N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑ Y2 to 1" > 1"
Facade Description: _ ~
Roof
• fit .
Debris: No Visible /Fine ayer ❑ /2 to 1" .1 ; ❑ > 1" 1
Description:
Setbacks N/A ❑
Floor: Debris No Visible/Fine Layer ❑%2 to 1"
Floor: Debris: No Visible/Fine Layer ❑ Y2 to 1"
Floor: Debris: ❑ No Visible/Fine Layer 0Y2 to 1"
Floor: Debris: ❑ No Visible/Fine Layer ❑/2to1"
Floor: Debris: ❑ No Visible/Fine Layer ❑ % to 1"