70772.1
Premise Address:
WTC Visual Survey Form
p
(077 2 I 9
~
Block: Residential Commercial D Name of Building:
Lot: Mix Use Other
# of Sto es: AKA's:
Building Owner/Management Telephone Number. ( )
Name: FAX:
Address:
On Site Contact:
Name: Telephone Number.
Building Owner Management Activities
interior Survey Performed ❑ Yes Q No
Exterior Survey Performed ❑ Yes No
General Clean Up ❑ Yes No Locations:
ACM Clean Up ❑ Yes No Locations:
Air Monitoring []Yes ❑ No Locations:
Copies of All Reports and Data Requested 1J Yes
Visual inspection Results:
Facade:
Inspected Debris
North [j N/A Yes ❑ No [] No Visible/Fine Layer 934 to 1" D>1"
South
East
West
❑ N/A
0 N/A
D N/A
] Yes ❑ No
Yes ❑ No
HYesoNo
0 No Visible/Fine Layer 934 to 1"
No Visible/Fine Layer D4 to 1"
❑ No Visible/Fine Layer 934 to 1"
0>1"
0>1"
0>1"
Facade Description: ^ n A
Roof
Debris: o Visible /Fine Layer ❑ 14 to 1" 9>1"
Description:
Setbacks N/Af
Floor. Debris: ❑ No Visible/Fine Layer 934 to 1" 0>1"
Floor Debris: 0 No Visible/Fine Layer ❑ i4 to 1" >1"
Floor____ Debris: 0 No Visible/Fine Layer h to 1" >1"
Floor Debris: 0 No Visible/Fine Layer 34 to 1" >10
Floor. Debris: ❑ No Visible/Fine Layer 034101" 9>1"
A building inventory and asbestos survey form for a WTC-related property, documenting structure details, facade condition by direction, and ACM locations.