Block: Residential 0 Commercial Name of Building:
Lot: 3 Mix Use fJ Other
# of Stories: AKA's: D z wSlit . t4 ' Z s.
Building Owner/Management: Telephone Number. ( ) 15 ;S.s s'
Name: FAX:
Address:
On Site Contact
Name: " ' Telephone Number.
Building Owner Management Activities
Interior Survey Performed ❑ 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 J Yes
Visual Inspection Results:
Facade:
Inspected Debris
North 0 N~JA 0 Ys 0 No 0 No Vsible/Fine Layer ❑ 34 to 1" [J>1"
South ( N/A es ❑ No [No Visible/Fine Layer ❑ % to? 0>1"
East ❑ IA ❑Yes ❑ No ❑ No Visible/Fine Layer [] % to 1" [J>1"
West E N/A des 0 No [' Visible/Fine Layer [] a to 1" [ -]:o- 1"
Facade Description:
Roof
Debris: ❑ No Visible /Fine Layer [] % to 1" 0>1"
Description:
Setbacks NIA[]
Floor Debris: j] No Visible/Fine Layer ❑ % to 1" ❑ >1"
Floor. Debris: j] No Visible/Fine Layer [} % to 1" [] > 1"
Floor____ Debris: ❑ No Visible/Fine Layer % to 1" 0>1"
Floor. Debris: ❑ No Visible/Fine Layer % to 1" ❑ > 1"
Floor: Debris: ❑ No Visible/Fine Layer % to 1" ❑ > 1"