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WTC Visual Survey Form
Premise Address:
c~—
Block: Resi ential Com a ci N3 o Bui
Lot: Mix Use 0 Other
# of Stories: AKA's: ® W
Building Owner1Manageent • Telephone Number.
Name: ~~ o - ~~ FAX: P ii
Address:
On Site Contact:
Name: Telephonebe Number: Z1L 23 3 G 1 G
Building Owner Management Activities
Interior Survey Performed Ses ❑ No
Exterior Survey Performed Yes ❑ No
General Clean Up Yes o Locations: (— J
ACM Clean Up ❑ es ❑ No Locations:
Air Monitoring ❑ Yes ❑ No Locations:
Copies of All Reports and Data Requested es
Visual Inscection Results: 7\
Facade:
Inpected De ris
North ❑ N/A ❑ No No Vsible/Fine Layer ❑ % to 1" 0>1"
South ❑NIA 7es ❑ No o Visible/Fine Layer 036 to 1" ❑ > 1"
East
West
❑ N/A
❑ N/A
Facade Description:
s ❑ No
s ❑ No
? o Visible/Fine Layer
NoVisibleTine Layer
❑ % to 1"
❑ Ya to l"
❑ > 1"
0>1"
Setbacks N/A ❑
Floor. Debris: ❑ No Visible/Fine Layer ❑ Ya to 1" ❑ > 1"
Floor. Debris: ❑ No Visible/Fine Layer ❑Va to 1" > 1"
Floor. Debris: ❑ No Visible/Fine Layer ❑ h to 1" H>1"
Floor: Debris: ❑ No Visible/Fine Layer ❑ Y: to 1" ❑ > 1'
Floor Debris: ❑ No Visible/Fine Layer ❑ S to 1" ❑ > 1"