WTC Visual Survey Form
riiiTieAddr.a*:
Block: Residential Commercial Name of Building:
Lot: Mix Use 0 Other
AKA's:
Building Telephone Number. ( )
Name: 9wnerlManaørent
~S FAX:
Address:
On Site Contact
Name: ' ' Telephone Number.
Building Owner Management Activities
Interior Survey Performed ❑ Yes[] No
Exterior Survey Performed Q Yes j] No
General Clean Up ❑ Yes No Locations:
ACM Clean Up j]Yes 9 No Locations:
Air Monitoring j] Yes j] No Locations:
Copies of All Reports and Data Requested Ej Yes
Visual insDection Results:
Facade:
Inspected Debris
North ❑ N/A DYes 0 No 9 No Visible/Fine Layer D4 to 1' 9>1'
South 9 N/A Yes 0 No No Visible/Fine Layer % to V >1'
East N/A DYes 0 No No Visible/Fine Layer % to V >1'
West j] N/A ❑ Yes j] No No Visible/Fine Layer 34 to? [J> 1'
Facade Description: /-)
Roof
Debris: Visible /Fine Layer j] % to V 9>1'
Description:
Setbacks N/A
Floor ____ Debris: j] No Visible/Fine Layer % to1' 9>1'
Floor____ Debris: 13 No Visible/Fine Layer % to 1' >1'
Floor____ Debris: L]No Visible/Fine Layer 36 to 1" >1"
Floor Debris: 0 No Visible/Fine Layer 34 to 1' 0>1'
Floor Debris: j] No Visible/Fine Layer [] 34 to V 9>1'
Comments