VI WTC Visual Survey Form 1p01q~ ~-
•1 rnise Address: I
Residential
t L
Block: (7 CommercialU I Name of Building:
Lot: c I Mix Use Other
# of Stories: AKA's: Z.<J c,✓
Building Owner/Management 1eleph e Number
Name: FAX:
Address:
On Site Contact
Name: " ' Telephone Number.
Building Owner Management Activities
Interior Survey Performed ❑ Yes 0 No
Exterior Survey Performed [] Yes 0 No
General Clean Up ❑ Yes ❑ No Locations:
ACM Clean Up ❑ Yes ❑ No Locations:
Air Monitoring 0 Yes ❑ No Locations:
Copies of All Reports and Data Requested DYes
visual Inspection Results:
Facade:
Inspected Debris
North ❑ N/A 9 Yes ❑ No Q No Visible/Fine Layer 0'A to 1' JJ > 1'
South N/A Yes ❑ No No Visible/Fine Layer '% to 1' > 1'
East N/A Yes ❑ No No Visible/Fine Layer i4 to 1' > 1'
West N/A HYesoNo No Visible/Fine Layer h to 1' > 1'
Facade Description: n _ J
Roof
Debris: No Visible /Fine Layer .9% to V 3> 1'
Description:
Setbacks WAa
Floor Debris: No Visible/Fine Layer 14 to 1' 3> 1'
Floor____ Debris: No Visible/Fine Layer % to 1' > 1'
Floor.____ Debris: 0 No Visible/Fine Layer 14 to 1' > 1'
Floor. p~bris: No Visible/Fine Layer 14 to 1' > 1'
Floor____ 'bris: No Visible/Fine Layer 34 to 1' H20 1'