WTC Visual Survey Form
Premise Address:
138- I L.E 7.. -
Block: Residential I Commercial jJ Name of Building:
Lot: Mix Use 0 Other
<# of Stories: AKA's:
Building Owner/Management Telephone Number: ( )
Name: FAX:
Address:
On Site Contact:
Name: - ' .. . . Nbp/ C' Telephone Number.
Building Owner Management Activities
Interior Survey Performed ❑ Yes ❑ No
Exterior Survey Performed ❑ Yes ❑ No
General Clean Up 0 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 fe N/A ❑ Yes ❑ No No Visible/Fine Layer ❑ % to 1" ❑ > 1'
South ❑ N/A Yes ❑ No No Visible/Fine Layer ❑ % to 1' ❑ > 1"
East RN/A ]Yes ❑ No DNoVisibIe1FineLayer ❑ Va to 1' 0>1"
West P N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑ % to 1" 0>1"
Facade Description:
Roof
Description:9~NoVsible /Fine Layer
Debris: .[] % to 1"
Setbacks N/A ❑
Floor. Debris: 0 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 ❑% to 1" ❑ > 1'
Floor. Debris: ❑ No Visible/Fine Layer ❑ 34 to 1" ❑ > 1'