WTC Visual Survey Form
Premise Address:
4S ,lam 1 C
Block: Residential Commercial Name of Building:
Lot: Mix Use 9 Other
# of Stories: 4 AKA's: - itne ST
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 Q No Locations:
Air Monitoring [J Yes Q No Locations:
Copies of All Reports and Data Requested Yes
visuai inspection Kesuits:
Inspected Debris
North ❑ N/A j jYesONo ❑ No VisiblelFine Layer t 134 to 1" ❑ > 1"
j] N/A ❑ No Visible/Fine Layer
South
East
West
❑ N/A
❑ N/A
DYes 0 No
❑ Yes ❑ No
❑ Yes ❑ No
0 No Visible/Fine Layer 8
34 to 1"
% to 1"
❑ No Visible/Fine Layer L'] h to 1"
> 1"
g > 1"
❑ > 1"
Facade Description:
Roof ysr
Debris: [] No Visible /Fine yer Q 34 to 1" 1=~"' 9' 1" )
Description: irf5i'ftrC-f ç:,; 4'-3 1AP<PL
Setbacks N/A B
Floor. Debris: ❑ No Visible/Fine Layer ❑ 34 to 1" > i"
Floor. Debris: ❑ No Visible/Fine Layer ❑ 34 to V > 1"
Floor: Debris: ❑ No Visible/Fine Layer D 34 to 1" > 1"
Floor. Debris: No Visible/Fine Layer ❑ %4 to 1" >V
Floor. Debris:E] No Visible/Fine Layer Q 34 to 1" >V
Comments ,A
Wr'