WTC Visual Survey Form ., F
Premise Address: D c ` i
V a 1
Block: Residential U Commercial D Jame of1Buildin :
Lot: Mix Use 0 Other 0 C/~ b
# of Stories: AKA's:
Building Owner/ anagerlient: ~j Telephone Number: ( )
Name: 1 L 1-( -' FAX:
Address:
On Site Contact:
Name: • Telephone Number:
Building Owner Management Activities
Interior Survey Performedges [] No
Exterior Survey Perfo ed es ❑ No
General Clean Up` es ❑ No Locations:
ACM Clean Up 'Yes ❑ No Locations:
Air Monitoring Yes No Locations:
Copies of All Reports and Data Re ueste Yes
Visual Inspection Results: r \
Facade:
Inspected Debris
North ,N/A ❑ Yes 0 No ❑ No Visible/Fine Layer ❑ % to 1" ❑ > 1"
South , N/A ❑ Yes ❑ No I No Visible/Fine Layer ❑ % to 1" ❑ > 1"
East ❑N/A QYes ❑ No No Visible/Fine Layer ❑ % to 1" ❑ > 1"
West ❑ N/A j l Yes ❑ No 1 NoVisibleIFineLayer ❑ % to 1" 0>10
Facade Description:
Roof
Debris: No Visible /Fine Layer 0% to 1" ❑ > 1"
Description:
Setbacks N/A ❑
Floor: Debris: 0 No Visible/Fine Layer ;❑ /2 to 1" ❑ > 1"
Floor: Debris: ❑ No Visible/Fine Layer 0 V to 1" > 1"
Floor: Debris: ❑ No Visible/Fine Layer ❑ % to 1" B>ift
Floor: Debris: ❑ No Visible/Fine Layer ❑ % to 1" ❑ > 1"
Floor: Debris: 0 No Visible/Fine Layer ❑ % to 1" ❑ > 1"