WTC Visual Survey Form 1000 -,.3 1
Premise Address:
Block: ó Residents Commercial p Name of Building:
Lot: ( MixUseD erjJ
S of Stories: AKA's: c,r -( -(
Building Owner/Management Telephone Nu r.
Name: 3 -e-' & G FAX:
Address:
On Site- Conta
Name: ' Telephone Number
Building Owner Managem t Activities
Interior Survey Performed ❑ Yes ❑ No
Exterior Survey Performed ❑ Yes 0 No
General Clean Up ❑ Yes ❑ No Locations:
ACM Clean Up ❑ Yes ❑ No Locations:
Air Monitoring [] Yes[] No Locations:
Copies of All Reports and Data Requested JJ Yes
Visual InsDection Results:
Facade:
Inspected Debris
North ❑ N/A ❑ YesQNo ❑ No Visible/Fine Layer ❑ ~4 to 1' D>1
South ❑ N/A ❑ YesQNo ❑ No Visible/Fine Layer 3'4to1 .
~ >1
East ❑ N/A ❑YesQNo ❑ No Visible/Fine Layer ❑'/ to 1' D>1•
West 0 N/A ❑ Yes,Q No 0 Nqd Visible/Fine Layer ❑%to1 0>1'
Facade Description: n () „
Roof
Debris: No Visible /Fine Layer D % to 1' D > 1'
Description:
Setbacks N/A ❑
Floor____ Debris: Q No Visible/Fine 4 to 1' ❑ > 1'
Floor____ Debris:D No Visible/Fine Layer
Layer8%tole 0>1.
Floor____ Debris: 0 No Visible/Fine Layer % to? 0>1.
Floor: Debris: 0 No Visible/Fine Layer % to? >1
Floor: Debris: ❑ No Ysible/Fine Layer % to?
Comments