Block: I Residehtial 0 Commercial jj Name of Building:
Lot J,fl Mix Uses Other
# of Stores: AKA's:
Building Owner/Management: Telephone Number. ( )
Name: Mc- FAX:
Address:
On Site Contact:
Name: fr .1 Yb Telephone Number.
Building Owner Management Activities
interior Survey Performed ❑ Yes Q No
Exterior Survey Performed 8 Yes 0 No
General Clean Up ❑ Yes 9 No Locations:
ACM Clean Up ❑ Yes 9 No Locations:
Air Monitoring 9 Yes ❑ No Locations:
Copies of All Reports and Data Requested j Yes
Visual Inspection Results:
Facade:
Inspected Debris
North ❑ NIA ❑ Yes ❑ No ❑ No Visible/Fine Layer 0 % to 1" 0>1"
❑ % to l"
South
East
West
❑ N/A
❑ N/A
❑ N/A
❑ Yes rl No
[]
Yes No
Yes ❑ No
R No Visible/Fine Layer
No Visible/Fine Layer
0 No Visible/Fine Layer
❑ % to l"
❑%tol"
0>1"
0>1"
0>1"
Facade Description: -n
Roof
Debris: No Visible /Fine Layer .❑ 34 to 1" 0>1"
Description:
Setbacks N/A
Floor. Debris:DNo Visible/Fine Layer 04 to 1" 0>1"
Floor. Debris: ❑ No Visible/Fine Layer '/% to 1" ❑>1"
Floor. Debris: 0 No Visible/Fine Layer a to 1" 9>1"
Floor. Debris: No Visible/Fine Layer % to 1" >I"
Floor: Debris: No Visible/Fine Layer % to 1" >1 "