WTC Visual Survey Form I DC) I b(2
Premise Address:
1:35- w r fl d /
Block: Residential El Commercial 0 Name of Building:
Lot: Mix Use Other ❑
# of Sto es: v 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 ER N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑ % to 1" []>i"
South ®N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑ % to 1" 0>1"
East ❑ N/A ® Yes ❑ No ®No Visible/Fieae yer ❑ % to 1" ❑ > 1"
West ❑ N/A [0 Yes ❑ No ® No Visible/der ❑ % to 1" ❑ > 1"
Facade Description: