Block: ResidentialD Commercial Name of Building:
Lot: Mix Use fl Other
# 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 Yes
Visual Inspection Results:
Facade:
Inspected Debris
North s ❑ No 'No Visible/Fine Layer ❑ % to 1' ❑ > 1'
South [EN1A ❑ No 0110 Visible/Fine Layer [3% to 1' ❑ >V
East ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑'h to 1' 0>1'
West ❑ N/A 0 Yes ❑ No ❑ No Visible/Fine Layer ❑ % to 1' 0>1'
Facade Description:
Roof
Debris: 2' o Visible /Fine Layer .❑
% to 1' 0>1'
Description:
Setbacks N/A L]
Floor. Debris: ❑ No Visible/Fine Layer ❑ Va to V 0>1'
Floor. Debris: ❑ No Visible/Fine Layer ❑ Y: to 1' ❑>1'
Floor. Debris: ❑ No Visible/Fine Layer 0 Ys to V ❑>1'
Floor. Debris: ❑ No Visible/Fine Layer ❑ 7h to 1' ❑>1'
Floor. Debris: ❑ No Visible/Fine Layer [] Va to 1' 0> 1'
Comments