WTC Visual Survey Form
Premise Address:
40 -
Block: Residential J Commercial Name of Building:
Lot Mix UseD Other
# of Stories: AKA's:
Building Ovyner/Management: Telephone Number.
Name: N )N FAX:
Address:
On Site Contact:
Name: ' ' T 41 S )Telephone Number.
Building Owner Management Activities
Interior Survey Performed Yes Q No
Exterior Survey Performed Yes Q No
General Clean Up Yes No Locations:
ACM Clean Up Yes No Locations:
Air Monitoring ❑ Yes No Locations:
Copies of All Reports and Data Reguestedfl Yes
Visual inspection Results:
Facade:
Inspected . Debris
North N/A Yes No No Visible/Fine Layer i4 to 1' > 1'
South N/A Yes No No Visible/Fine Layer K to 1' 0>1'
East N/A Yes No No Visible/Fine Layer ❑%to1' >1'
West N/A HYesoNo No Visible/Fine Layer ❑%to1' >i.
Facade Description: ,-
n
Roof
Debris: No Visible /Fine Layer .0 % to 1'
Description:
Setbacks WAd
Floor___ Debris: No Visible/Fine Layer y4 to 1' 9>1.
Floor___ Debris: No Visible/Fine Layer 3% to 1 >1
Floor____ Debris: No Visible/Fine Layer 34 to 1' > 1'
Floor: Debris: No Visible/Fine Layer % to 1' >1'
Floor.____ Debris: No Visible/Fine Layer % to 1' >1'
Comments .
4,