WTC Visual Survey Form .,
remise Address: C) ~_( a
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Block: 5 j Residential 0 Commercial Jame o '*
Lot: Mix Use ❑ Other BuMb
# of Stories: AKA's: Y, J
Building Owner/ anage9ent: / Telep 1Ia Number: ( )
Name: Q,)L 1_ A ('\ FAX:
Address:
On Site Contact:
Name: Telephone Number:
Building Owner Management Activities
Interior Survey Performed Yes ❑ No
Exterior Survey Perfo ed ❑ No
General Clean Up es ❑ No Locations:
ACM Clean Up Yes ❑ No Locations:
Air Monitoring Yes No Locations:
Copies of All Reports and Data ReguestecjYes
Visual Inspection Results: v \
Facade:
Inspected Debris
North ,N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑ Y2 to 1" ❑ > 1"
South , N/A ❑ Yes ❑ No fl No Visible/Fine Layer ❑ % to 1" ❑ > 1"
East ❑ N/A EYes ❑ No No Visible/Fine Layer ❑ % to 1" ❑ > 1"
West ❑ N/A Yes ❑ No No Visible/Fine Layer ❑'/2 to 1" ❑ > 1"
Facade Description:
Roof
Debris: No Visible /Fine Layer ❑ % to 1" ❑ > 1"
Description:
Setbacks N/A ❑
Floor: Debris: ❑ No Visible/Fine Layer ❑ Y2 to 1" ❑ > 1"
Floor: Debris: ❑ No Visible/Fine Layer ❑ '/2 to 1" ❑ > 1"
Floor: Debris: 0 No Visible/Fine Layer ❑ Y2 to 1" ❑ > 1"
Floor: Debris: ❑ No Visible/Fine Layer ❑ 1/z to 1" ❑ > 1"
Floor: Debris: ❑ No Visible/Fine Layer ❑ Y2 to 1" ❑ > 1"