WTC Visual Survey Form (00 (Qq3
Premise Address:
L 'L j'
Block: 1-7 C I Resideritialfl
Residential Commercial JJ I Name of Building:
Lot: Mix Use OtherEJ I
# of Stories: e I AKA's: (-3
Buiidin Owrpr/Mana ement:
/pho a Number. ( )
€o
Name: t,ub 6~ N
Address:
On Site Contact:
Name: " b QC Velephone Number:
Building Owner Management Activities
Interior Survey Performed ❑ Yes ❑ No
Exterior Survey Performed ❑ Yes ❑ 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 I I Yes
Visual Inspection Results:
Facade:
Inspected Debris
North 2f 1/A ❑ Yes ❑ No No Visible/Fine Layer ❑%to1" 0>1"
South ❑ N/A [kfes ❑ No No Visible/Fine Layer ❑'/ to 1" 0>1"
East Q'N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑'/ to 1" 0>1"
West [-N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑%to1" 0>1"
Facade Description:
Roof
Debris: (3o Visible /Fine Layer ❑ Va to 1" 0>10
Description:
tv A bs4
Setbacks N/A [V
Floor. Debris: ❑ No Visible/Fine Layer 0 ¶4 to V
Floor. Debris: ❑ No Visible/Fine Layer ❑ a to 1"
Floor: Debris: ❑ No Visible/Fine Layer 0 h to 1"
Floor: Debris: ❑ No Visible/Fine Layer 0
V to 1"
Floor: Debris: ❑ No Visible/Fine Layer ❑ 6 to 1"
Comments