Block: Residential 0 Commercial Name of Building:
Lot: Mix Use Other 0 2-,-r LLB g g- i k
# of Stories: AKA's:
Building Owner/Management: Telephone Number: ( )
Name: FAX:
Address:
On Site Contact:
Name: • ' .. . Telephone 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 J Yes
Visual inspecuon Results:
Facade:
Inspected Debris
North ❑ N/A ❑ Yes ❑ No ❑ No Vsible/Fine Layer ❑ Ya to 1" 0>1"
South ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑ % to 1" 0>1"
East ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑ % to 1" 0>1"
West ❑ N/A ❑ Yes ❑ No ❑ No VSible/Fine Layer ❑ Ya to 1" 0>1"
Facade Description: