Block: qo Residential 0
J Commercial p f Name of Building:
Mix Use Other _ —
Lot fl
# of Stories: AKA's:
Building OwnerlManagement: 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 j] Yes ❑ No Locations:
Copies of All Reports and Data Requested DYes
Visual inspection resume:
Facade:
Inspected Debris
North ❑ N/A ❑Yes ❑ No ❑ No Visible/Fine Layer ❑'/tol" 0>1"
South ❑ N/A ❑ Yes [] No ❑ No Visible/Fine Layer ❑%to l" 0>1"
East ❑ NIA ❑Yes ❑ No ❑ No Visible/Fine Layer ❑%tol" 0>1"
West ❑ N/A ❑ Yes ❑ No .❑ No Visible/Fine Layer ❑%to l" 0>1"
Facade Description:
Roof
Debris: 0 No Visible !Fine Layer ❑ h to 1" >1
Description:
Setbacks NIA ❑
Floor. Debris: 0 No Visible/Fine Layer ❑ % to 1" 0>1"
Floor ____ Debris: ❑ No Visible/Fine Layer ❑ %to 1" 0>1"
Floor Debris: ❑ No Visible/Fine Layer ❑ % to 1" 0>1"
Floor____ Debris: ❑ No Visible/Fine Layer ❑ h to 1" 0>1"
Floor.____ Debris: ❑ No Visible/Fine Layer ❑ % to 1" 0>1"