WTC Visual Survey Form /o v q 17 9
Pror:ise Address•
Block: Residential Commercial Name of Building:
Lot: , is
Mix UseD 0therfl
0 of Stories: AKA's:
Building Owner/Management Telephone Number ( )
Name: FAX:
Address:
On Site Contact:
Name: ' ' Telephone Number.
Building Owner Management Activities
A.. Interior Survey Performed ❑ Yes Q No
Exterior Survey Performed ❑ Yes No a
General Clean Up ❑ Yes ❑ No Locations:
ACM Clean Up ❑Yes ❑ No Locations:
Air Monitoring ❑ Yes ❑ No Locations:
Copies of All Reports and Data Requested fl Yes
Visual Inspection Results:
Facade:
Inspected Debris
North ❑ N/A ❑ YesQNo ❑ No Visible/Fine Layer ❑ % to 1 ❑ > 1'
South ❑ N/A ❑ YesQNo ❑ No Visible/Fine Layer ❑%to 1' 0>?
East ❑ N/A ❑ YesQNo O No Visible/Fine Layer ❑%to 1' 0>?
West ❑ N/A ❑ YesQNo ❑ No Visible/Fine Layer 0%to1' ❑>1'
Facade Description: /A A _
I
Setbacks Wi
Floor Debris: ❑ No Visible/Fine Layer ❑ % to? 0>1.
Floor____ Debris: ❑ No Visible/Fine Layer 0 % to V 0>1.
Floor . Debris: ❑ No Visible/Fine Layer ❑ % to V ❑ > 1'
Floor. Debris: 0 No Visible/Fine Layer ❑ % to 1' ❑ > 1'
Floor` Debris: 0 No Visible/Fine Layer 0 % to 1' 0>1.
Comments A