WTC Visual Survey Form
Premise Address: f-1 1 k-1 U i J,
U - ~ +(
Block: Residential f J Commer ialEl N Bu)lc~In :~~
Lot: Mix Use Other l c: n ww
# of Stories: 3 AKA's:
Building Owner/Management: Telephone Number: ( )
Name: FAX:( )
Address:
On Site Contact:
Name: I;;'1 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 j"N/A Yes ❑ No No Visible/Fine Layer ❑'/to1" 0>1"
South ' N/A RYes ❑ No ❑ No Visible/Fine Layer 0%to1" 0>1"
❑ N/A Yes ❑ No
East
West ❑ N/A
Facade Description:
81
'Yes ❑ No
• No Visible/Fine Layer ElY2 to 1"
-allo Visible/Fine Layer 0Y2to1"
0>1"
0>1"