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V
VYTC Visual Survey Form (00336
Premise Address:
lock: Residential CommercialD Name of Building:
Lot: I Mix UseD Otherlj
# of Sto U I AKA's:
Building Owner) lanageme t: Telephone Number. ( 1
Name: !--I- FAX:
Address: 100 p
On Site Contacts
Name: ' ' -' Telephone Number.
Building Owner Management Activities
Interior Survey Performed IJ Yes 0 No
Exterior Survey Performed DYesIJ 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 fl Yes
Visual Inspection Results:
Facade:
Inspected Debris
North ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer El % to 1' D> 1'
South 0 N/A ❑ Yes ❑ No No Visible/Fine Layer 34 to 1' ❑ > 1'
East ❑ N/A a Yes Q No No Visible/Fine Layer 034t01' 9>1'
West a N/A 9 Yes,[J No _ No~ Visible/Fine Layer ❑ 4 to 1' ❑ > 1'
Facade Description: n V ,~
Roof
Debris: No Visible /Fine Layer -0 % to 1' 0>1 '
Description:
Setbacks N/A
Floor.____ Debris: No Visible/Fine Layer ❑ 6 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 34 to 1' > 1'
Floor Debris: No Visible/Fine Layer % to 1' >1'