WTC Visual Survey Form
'Premise Address: ~
Y/
Block: Reside tial Comme j Name of Building:
Lot: y Mix UseD OtherlJ
# of Stories: AKA's:
Building Owner/Ma Telephone Number. (
Name: FAX:(
Address:
On Site Contact
Name: ' Telephone Number.
Building Owner Management Activities
Interior Survey Performed ❑ Yes Q No
Exterior Survey Performed ❑ Yes ❑ No
General Clean Up ❑ Yes Q No Locations:
ACM Clean Up ❑ Yes Q No Locations:
Air Monitoring Q Yes Q No Locations:
Copies of All Reports and Data Requested j Yes
Visual Insoectlon Results:
Facade:
Inspected Debris
North [] N/A Q Yes 0 No ❑ No Visible/Fine Layer ❑ ~4 to 1" Q > 1"
South ❑ N/A Yes 0 No 0 No Visible/Fine Layer ❑ 3~4 to 1" ❑ > 1"
East ❑ N/A HYesoNo ❑ No Visible/Fine Layer ❑ h to V Q > 1"
West ❑ N/A Q %es Q No ❑ Np Visible/Fine Layer 034t01' D>1•
Facade Description: () u
Roof
Debris: Visible /Fine Layer r] % to V Q >V
Description:
Setbacks N/A
Floor.____ Debris: ❑ No Visible/Fine Layer %to 1" D> 1"
Floor____ Debris: 0 No Visible/Fine Layer H%tolo > 1"
Floor. Debris: 0 No Visible/Fine Layer ❑ % to 1" > 1"
Floor Debris: Q No Visible/Fine Layer 36 to 1" > 1"
Floor____ Debris: Q No Visible/Fine Layer H%tolw Q > 1"
Department of Environmental Protection inspection form for WTC-area building documenting facade condition, asbestos, and other environmental hazard assessments.