f• ti WTC Visual Survey Form 1001007
remise Address:
70 i'i
Block: %4 Residential 0 Commercial Name of Building:
Lot: % Mix UseD Other 0 4i
# of Stories: 6 • AKA's:
Building Owner/Management: Telephone Number: (2J t_)
Name: rJoI FAX:
Address:
On Site Contact: , ~,~;,~
Name: 1jc Telephone Number:
Building Owner Management Activities
Interior Survey Performed ❑ Yes ❑ No
Exterior Survey Performed ❑ Yes ❑ No
General Clean Up BYes ❑ No Locations:
ACM Clean Up ❑ Yes ❑ No Locations:
Air Monitoring EYes ❑ No Locations:
Copies of All Reports and Data Requested f J Yes
visual msoection Kesul s:
Facade:
Inspected Debris
North ❑ N/A ® Yes ❑ No g( No Visible/Fine-Layer ❑'/2 to 1" [J > 1"
South ❑ N/A ® Yes ❑ No iNo Visible/Finc Layer ❑'/ to 1" ❑ > 1"
East ❑ N/A g] Yes ❑ No 'No Visible/Fine-gayer ❑ Va to T' ❑ > 1"
West ❑ N/A N Yes ❑ No No Visible/Finc Layer- ❑ % to 1" ❑ > 1"
Facade Description:
Roof
Debris: No Visible /Fine Layer ❑ % to 1" ❑ > 1"
Description:
Setbacks N/A® iviX p c
Floor: Debris: ❑ No Visible/Fine Layer ❑ Va to 1" ❑ > 1"
Floor. Debris: ❑ No Visible/Fine Layer ❑ 1/ to 1" ❑ > 1"
Floor. Debris: ❑ No Visible/Fine Layer ❑'/% to 1" ❑ > 1"
Floor. Debris: ❑ No Visible/Fine Layer ❑ % to? ❑ > 1"
Floor: Debris: ❑ No Visible/Fine Layer ❑ % to 1" ❑ > 1"