WTC Visual Survey Form
~oO 10l9
Premise Address:
O LL STREET
Block: 143 Residential ❑ Commercial Name of Buildin
Lot: Mix Use ❑ Other ❑ 30 (,C- ,
# of Stories: AKA's:
Building O ner/ agement: Telephone Number: ( )
Name: (` FAX: ( )
Address: t.t, l 00
On Site Contact:
Name: Telephone Number: ) )
Building Owner Management Activi i s
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 ❑ Yes
Visual Inspection Results:
Facade:
Inspected De ris
North ❑ N/A El Yes ❑ No 1No Visible/Fine Layer ❑ Y to 1" ❑ > 1"
South ❑ N/A ❑ Yes ❑ No No Visible/Fine Layer El 1/2 to 1" ❑ > 1"
East ❑ N/A ❑ Yes ❑ No No Visible/Fine Layer ❑'/z to 1" ❑ > 1"
West ❑ N/A ❑ Yes ❑ No o Visible/Fine Layer ❑'/z to 1" ❑ > 1"
Facade Description:
Roof
Debris: NcVisit e /Fine Layer ; A ' '/2 to 1" • ❑>1"
Description: 7An Av' Z c
Setbacks
Floor: Debris o Visible/Fine Layer El 1/2 to 1" ❑ > 1"
Floor: Debris: No Visible/Fine Layer '/2 to 1" ❑ > 1"
Floor: Debris: No Visible/Fine Layer El 1/2 to 1" ❑ > 1"
Floor: Debris: No Visible/Fine Layer El 1/2 to 1" ❑ > 1"
Floor: Debris: ❑ No Visible/Fine Layer El 1/2 to 1" ❑ > 1"