WTC Visual Survey Form V-9
'Premise Address:
21,3 p4 S/'4 •
Block: Residential 0 Commercial D Name of Building:
Lot: 5 Mix Use j 1 Other
# of Stories: AKA's:
Building Owner/Management: Telephone Number: ( )
Name: FAX:
Address:
On Site Contact:
Name: * 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 insoection Results:
Facade:
Inspected Debris
North tgN/A ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑Yzto 1" 0>1"
South g N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑Mato 1" 0>1"
East ❑ N/A J Yes ❑ No [ No Visible/Fine Layer ❑Vator 0>1"
West NIA DYesDNo 0 No Visible/Fine Layer ❑%to1" 0>1"
Facade Description:
Roof
Debris: [~ Fine Layer ❑ Ya to 1" 0>1"
Description: i ispecled fr trrr, ao p2 r1 S e-b
Setbacks N/A j~7J
Floor. Debris: ❑ No Visible/Fine Layer ❑ V to 1" ❑ > 1"
Floor. Debris: 0 No Visible/Fine Layer ❑ Va to 1" ❑ > 1"
Floor. Debris: ❑ No Visible/Fine Layer ❑ Va to 1" ❑ > 1"
Floor. Debris: ❑ No VSible/Fine Layer ❑ Va to? ❑ > 1"
Floor. Debris: 0 No Visible/Fine Layer 0 % to 1" ❑ > 1"