Premise Address: q 0 1 e sT f
W S,
Block: Residential 0 Commercial Name of Building:
Lot: Mix Use 0 Other 0
# of Stories: AKA's:
Building Owner/Management Telephone Number (( i ~) I4 }
Name: C c- w FAX:
Address:
On Site Contactc -vr-
Name: QA -k- Telephone Number t q 1 Sc (
Building Owner Managem nt ctivities
Interior Survey Performed [] , Yes ❑ No
Exterior Survey Performed QYYes ❑ No
General Clean Up J2 Yes ❑ No Locations:
ACM Clean Up D`Yes ❑ No Locations:
Air Monitoring Yes ❑ No Locations:
Copies of All Reports and Data Requested es
Visual Inspection Results:
Facade:
Inspected Debris
North ❑ N/A ,l(Yes ❑ No allo Visible/Fine Layer ❑ % to 1" ❑ > 1"
South ❑ N/A f Yes ❑,No No Visible/Fine Layer ❑ % to 1" ❑ > 1"
East ❑ N/A /E] es ❑ No O No Visible/Fine Layer ❑ % to 1" ❑ > 1"
West ❑ N/A Eyes ❑ No No Visible/Fine Layer ❑ % to 1" ❑ > 1"
Facade Description:
Roof
Debris: Vo Visible /Fine Layer ❑ % to l" ❑ > 1"
Setbacks N/A ❑
Floor. Debris: ❑ No Visible/Fine Layer ❑ V to 1" 0>1"
Floor: Debris: ❑ No Visible/Fine Layer ❑ Y2 to 1" [1>1"
Floor: Debris: ❑ No Visible/Fine Layer ❑ Y2 to 1" ❑ > 1"
Floor: Debris: ❑ No Visible/Fine Layer ❑'/ to 1" ❑>1"
Floor: Debris: ❑ No Visible/Fine Layer 0 % to 1" ❑> 1"