100120si
WTC Visual Survey Form
Premise A
R
Block: Residential Commercial Name of Building:
Lot: Mix Use Other
# of o es: 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:
Coles of All Reports and Data Requested I Yes
Visual Inspection Results:
Facade:
Inspected Debris
North ❑ N/A ❑ Yes ❑ No ❑ No ViSible/Fine Layer ❑%to1" 0>1"
South ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑ % to l" 0>1"
East ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑ 4 to l" 0>1"
West ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑%tol" 0>1"
Facade Description:
Roof
Debris: ❑ No Visible /Fine Layer ❑%to1" ~>1"
Description:
Setbacks N/A ❑
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 ❑'/Z to 1" ❑ > 1"
Floor. Debris: ❑ No Visible/Fine Layer ❑Y to 1" ❑ > 1"