WTC Visual Survav Form I/
Premise Address:
73U
Block: Residential merciai D Name of Building:
Lot: Mix Use Other
# of Stories: AKA's:
Building Owr~er/M nagement: Telephone Number. (2i2 I
Name: K ~ FAX:
Address:
On Site Contact:
Name: Telephone Number:
Building Owner Manage ent Activities
Interior Survey Performed [ayes ❑ No
Exterior Survey Perfo ed ~'es ❑ No
General Clean Up JY Yes ❑ No Locations:
ACM Clean Up ❑ Yes ❑ No Locations:
Air Monitoring Yes ❑ No Locations:
Copies of All Reports and Data Requested Yes
Visual Inspection Results:
Facade:
Inspected Debris
North ❑ N/A [Z Yes ❑ No ❑ No Visible/Fine Layer ❑ %a to l" 0>1"
South ❑ N/A ( "Yes ❑ No ❑ No Visible/Fine Layer ❑'/ to 1" ❑ > 1"
East ❑ N/A f Yes ❑ No ❑ No Visible/Fine Layer ❑ % to 1" ❑ > 1"
West ❑ N/A f3Yes 0 No ❑ No Visible/Fine Layer ❑ Va to 1" ❑ > 1"
Facade Description:
'l C2
Roof
v
Debris: No Visible /Fine yer ❑ Ya to 1" 1-~"'' ❑ > 1" 1
Description:
Setbacks
Floor. ____ Debris: ❑ No Visible/Fine Layer ❑'/ to 1" ❑ > 1"
Floor. Debris: 0 No Visible/Fine Layer 0 Va to 1" [3> 1"
Floor. Debris: ❑ No Visible/Fine Layer ❑ %a to 1" [3 >10
Floor. Debris: ❑ No Visible/Fine Layer ❑ %a to 1" ❑ > 1"
Floor. Debris: ❑ No Visible/Fine Layer ❑ % to 1 " ❑ > 1"
Comments