WTC Visual Survey Form
Premise Address: p
Block: I Residential D Commercial D Name of Building:
Lot: Mix Use Other
# of Stories: tL4 AKA's:
Building Owner/Management:
D~ Telephone Number: ( )
Name: ~t. Ft SKw<_ * So+- FAX:
Address:
On Site Contact: -,,Z
Name: - * C - t- EMe~scNx C-2 Telephone Number. ( ) 60$ S~zZ
Building Owner Management Activities
Interior Survey Performed ❑Yes ❑ No
Exterior Survey Performed ❑ Yes 0 No
General Clean Up )x Yes ❑ No Locations: ___ " _____
ACM Clean Up ❑ Yes ❑ No Locations:
Air Monitoring ❑ Yes ❑ No Locations:
Copies of All Reports and Data Requested Yes