WTC Visual Survey Form
Premise Address:
3 i s
Block: Residential Cdmmercial 0 Name of Building:
Lot: p Mix Use ❑ Other ❑
## of Stories: 2-- AKA's:
Building Ow r/Ma agement: Telephone Number: (4 -~ `>~ Z 73 (b
Name: ~~"~^ --6-a -(-~ ~'~l ~~ ~-.,—e'A 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 [j'Yes ❑ No Locations:
ACM Clean Up ❑ Yes ❑i No Locations:
Air Monitoring DYes ❑ No Locations:
Copies of All Reports and Data Requested Yes
visual inspection Keswts:
Facade:
Inspected Debris
North ❑ N/A Ef Yes ❑ No ❑ No Visible/Fine Layer ❑ 1/2 to 1" ❑ > 1"
South ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑ 1/2 to 1" ❑ > 1"
East ❑ N/A 0 Yes ❑ No ❑ No Visible/Fine Layer ❑ Y2 to 1" ❑ > 1"
West ❑ N/A ❑'Yes ❑ No ❑ No Visible/Fine Layer ❑ Y2 to 1" ❑ > 1"
Facade Description:
Roof
' t
Debris: No Visible /Fine ayer ❑'/2 to 1" '1 ~"`' ❑ > 1" 1
Description:
Setbacks N/A;J
Floor: Debris: ❑ No Visible/Fine Layer ❑'/2 to 1" ❑ > 1"
Floor: Debris: ❑ No Visible/Fine Layer ❑'/2 to 1" ❑ > 1"
Floor: Debris: ❑ No Visible/Fine Layer ❑ '/2 to 1" ❑ > 1"
Floor: Debris: ❑ No Visible/Fine Layer ❑ 1/ 2 to 1" ❑ > 1"
Floor: Debris: ❑ No Visible/Fine Layer ❑'/2 to 1" ❑ > 1"