WTC Visual Survey Form
Premise Address: Q (4V L /0
4 %
Block: Residentia1.L Commercial Name of Building:
Lot: Mix Use Ot er
# of Stories: AKA's:
Building Owner/Management Telephone Number. ( )
Name: FAX:
Address:
On Site Contact
Name: - ' Telephone Number.
Building Owner Management Activities
Interior Survey Performed 0 Yes ❑ No
Exterior Survey Performed 0 Yes 0 No
General Clean Up ❑ Yes 0 No Locations:
ACM Clean Up ❑ Yes Q No Locations:
Air Monitoring ❑ Yes ❑ No Locations:
Copies of All Reports and Data Requested Yes
Visual Inspection Results:
Facade:
n ected De $
North 0 N/A es Q No o Visible/Fine Layer ❑'h to 1" ❑ > 1"
South 0 N/A es Q No No Visible/Fine Layer ❑ % to 1" ❑ > 1"
East +l/A ❑ Yes Q No ❑ No Visible/Fine Layer ❑ h to 1" 0>1"
West ❑ N/A es ❑ No Visible/Fine Layer 0
Y to 1" ❑ > 1"
Facade Description: //
Roof
Debris: o Visible /Fine Layer ❑'h to 1" ❑ > 1"
Description:
VS ,4 t W.P) fr
Setbacks N/A ❑
Floor. Debris: ❑ No Visible/Fine Layer ❑'% to 1" ❑ > 1"
Floor. Debris: ❑ No Visible/Fine Layer ❑'h to 1" 0> 1"
Floor: Debris: ❑ No Visible/Fine Layer ❑'h to 1" 0> 1"
Floor: Debris: ❑ No Visible/Fine Layer ❑'h to 1" ❑ > 1"
Floor. Debris: ❑ No Visible/Fine Layer ❑ i4 to 1" ❑ > 1"