WTC V Survey Form
Premise Address:
lei — a1 \1'J S wf^4
Block: Residential D Commercial D Name ot Building:
Lot: Mix Use Other ❑
# of S ories: AKA's:
Building Owner/Management: Telephone Number. ( )
Name: FAX:
Address:
On Site Contact:
Name: ~®vn 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 N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑ % to 1" 0>11*
South N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑'/tol" 0>1"
East N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑'/ to l" 0>1"
West N/A ®Yes lo ,JJNo Visible/Fine--L-eyer ❑Vato1" 0>1"
Facade Description: