WTC Visual Survey Form
Premise Address:
3' Li cuveM
Block: Residential 0 Commercial J Name of Building:
Lot: r Mix Use ❑ Other
# of Stories: 7 AKA's:
Building Owner/Management: Telephone Number: ( )
Name: FAX:
Address:
On Site Conta
Name: ~~-- ' LJ~c Telephone Number: ( )
Building Owner Management Activities
Interior Survey Performed ❑ YesJNo
Exterior Survey Performed ❑ Yes
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 Debris
North ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer E)'/2 to 1" 0>1"
South ❑ N/A ❑ No ~— o Visible/Fine Layer ❑'/2 to 1" ❑ > 1"
East ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑'/ to 1" ❑ > 1"
West ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer 0'/2 to 1" 0>1
Facade Description:
Roof
Debris: No Visible /Fine Layer ❑ h to 1" ` , 0>1"
Description:
Setbacks N/A ❑
Floor: Debris: ❑ No Visible/Fine Layer ❑ / to 1" ❑ > 1"
Floor: Debris: ❑ No Visible/Fine Layer 0
V to 1" ❑ > 1"
Floor: Debris: ❑ No Visible/Fine Layer ❑'/2 to 1" ❑ > 1"
Floor: Debris: ❑ No Visible/Fine Layer 0
V to 1" ❑ > 1"
Floor: Debris: ❑ No Visible/Fine Layer ❑ % to 1" ❑ > 1"
Odmments