WTC Visual Survey Form
Premise Address:
S
Block: . Resid ntialD Commercial e o Buil :
Lot: Mix UseD Other
# of Stories: AKA's:
Building Owner/Management Telephone Number ( )
Name: FAX:
Address:
On Site Contaçtj
Name: ' Telephone Number.
Building Owner Management Activities
Interior Survey Performed ❑ Yes Q No
Exterior Survey Performed Q Yes No
General Clean Up Q Yes Q No Locations:
ACM Clean Up Q Yes Q No Locations:
Air Monitoring Q Yes Q No Locations:
Copies of All Reports and Data Requested Yes
Visual Inspection Results:
Facade:
Ins acted 1brls
North [] N/A es Q No ØNo Visible/Fine Layer Q h to 1" 0> 1"
South N/A es Q No 'Q No Visible/Fine Layer Y to 1' ❑ > 1"
East
West
/A
A
Facade Description:
Yes Q No
L] Yes 0 No HNoVitible/Fine
No Visible/Fine Layer H%tolo
Layer Q Va to 1"
❑ > 1"
❑ >V
Roof
Debris: o Visible /Fine Layer %to 1" 9>1
Description: ()
Setbacks N/
Floor Debris: [] No Visible/Fine Layer ❑% to 1'
Floor. Debris: Q No Visible/Fine Layer Va to 1"
Floor.
Floor
Floor
Debris: 0 No Visible/Fine Layer
0
Debris: No Visible/Fine Layer H % to 1"
% to 1"
Debris: No Visible/Fine Layer 0 1/4 to 1"