VVTC Visual Survey Form
Premise Address:
oo
Block: Residential El Co mercjal El Name of Building:
Lot: Mix Use Othe -~' \ £'cam- ` t wb--.
# of Stories: AKA's:
Building Owner/Management: Telephone Nu ber: ( )
Name: FAX: ( )
Address:
On Site Contact: p ` 1
Name: o ow~w x,~ C ~-i4fTe1ephone Number: ( )
Building Owner ities
Interior Survey Performed Jes ❑ No
Exterior Survey Performed
ManagemeWes , ❑ No
General Clean Up E Yes ❑ No Locations:
ACM Clean es ❑ No Locations:
Air Monitoring
UpXesFINo locations:
Copies of All Reports and Data Re ueste es
Visual Inspection Results:
Facade:
Inspected Debris
North ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑'/ to 1" ❑ > 1"
South ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑ 1/ to 1" ❑ > 1"
East ❑ N/A es ❑ No ib Visible/Fine Layer ❑'/2 to 1" ❑ > 1"
-
West ❑ N/A 1 Yes ❑ No isible/Fine Layer ❑'/2 to 1" ❑ > 1"
Facade Description: