WTC Visual Survey Form 1000 17
Premise Address:
A a—
Block: g Residential 0 Commercial Name of Building:
Lot: Mix UseD Other
# of Stori s: AKA's:
Building Owner/Management: Telephone Number: ( )
Name: FAX:
Address:
On Site Contact:
Name: • * Telephone Number:
Building Owner Management Activities
interior Survey Performed j] Yes ❑ 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 Yes
Visual Inspection Results:
Facade:
Inspected Debris
North ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑'/s to 1" S 1"
South ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑ % to 1" 1"
East ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑ Y2 to 1" ms's 1"
West 0 N/A ❑ Yes 0 No ❑ No Visible/Fine Layer ❑'/z to 1" i r> 1"
Facade Description: cj
4 t
Roof Dist;
u I
Debris: ❑ No Visible /Fine yer ❑ V to 1" •4 clr~ 1"
Description:
Setbacks N/Az!
Floor. Debris: ❑ No Visible/Fine Layer ❑ Y2 to 1" 0>1"
Floor. Debris: ❑ No Visible/Fine Layer ❑ % to 1" 0>1"
Floor. Debris: ❑ No Visible/Fine Layer ❑ Va to 1" 0>1"
Floor. Debris: j] No Visible/Fine Layer ❑ Va to 1" ❑ > 1"
Floor. Debris: ❑ No Visible/Fine Layer ❑ Va to 1" 9>1"
P..mw~ente -