WTC Visual Survey Form ICoj 9~
Frerhise Address: f ,~ w
3 I I
dock: Residential Commercial Name o uiiding:
Lot: Mix Use Offer
# oY Stories: AKA's:
Building Owner/Management Telephone Number ( )
Name: FAX:(
Address:
On Site Contact:
Name: ' ' .. . Telephone Number.
Building Owner Management Activities
Interior Survey Performed HYesHNo
Exterior Survey Performed Yes No
General Clean Up DYes No Locations:
ACM Clean Up 0 Yes No Locations:
Air Monitoring O Yes O No Locations:
Copies of All Reports and Data Requested D Yes
Visual Inscection Results:
Inspected Debris
North ❑ N/A ❑ Yes D No' No Visible/Fine Layer 14 to 1' 1-131-10
South ❑ N/A Yes[] No No Visible/Fine Layer %to 1' 0>?
East N/A Yes O No No Visible/Fine Layer %to 1' ❑> 1'
West ON/A YesONo No Visible/Fine Layer %to 1' 0>?
Facade Description _
Roof
Debris: No Visible /Fine Layer .0 % to 1' 0> 1'
Description:
Setbacks N/AI,
Floor Debris: 0 No Visible/Fine Layer % to 1' > 1'
Floor Debris: No Visible/Fine Layer % to 1' > 1'
Floor Debris: [I No Visible/Fine Layer % to 1' > 1'
Floor Debris: No Visible/Fine Layer 34 to 1' > 1'
Floor____ Debris: No Visible/Fine Layer 03610? > 1'