Block: Residential 0 Commercial J J Name of Building:
Lot: O Mix Use Other
# of Stories: D AKA's:
Building Owner M ,nagerrtent I Telephone Number. (21Z)
Name: t9- ,u l 1r a FAX:
Address:
On Site Contact
Name: - ' Telephone Number:
Building Owner Management Activities
Interior Survey es Q'No
Exterior Survey Performed es ❑ No
General Clean Up ❑Yes
PerformedfTN Locations:
ACM Clean Up ❑ Yes Q N o Locations:
Air Monitoring ❑ Yes ['lo Locations:
Copies of All Reports and Data Requested es
Visual inspection Results:
Facade:
Inspected De is
North 0 -N/A ❑ Yes ❑ No Visible/Fine Layer ❑vto1" 0>1"
South 3 N/A ❑ s ❑ No D isible/Fine Layer ❑%to1" 0>1"
East ❑ N/A [Yes ❑ No sible/Fine Layer ❑ % to 1" 0>1"
West Q4J/A ❑Yes❑No PoVs1ble/Fine Layer ❑ % to 1" D>1"
Facade Description:
Roof
Debris: [-' "No Visible /Fine Layer ❑ % to 1" 0>1"
Description:
Setbacks N/A
Floor Debris: ❑ No Visible/Fine Layer ❑ 1/ to 1" ❑ > 1"
Floor. Debris: ❑ No Visible/Fine Layer ❑ % to 1" ❑ > 1"
Floor: Debris: ❑ No Visible/Fine Layer ❑ %: to 1" ❑ > 1"
Floor. Debris: ❑ No Visible/Fine Layer ❑ % to 1" ❑ > 1"
Floor. Debris: ❑ No Visible/Fine Layer ❑ h to 1" ❑ > 1"