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WTC Visual Survev Form
remise Address:
, FA1L:: -c-- -
Block: Residential 0 Commercial Name of Building:
Lot: Mix UseD Other
# of Stories: AKA's:
Building Owner/Management Telephone Number. ( )
Name: t.1 C 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 Regnested Yas
Visual insoection Results:
Facade:
Inspected Debris
North [] NIA DYesDNo No Visible/Fine Layer 34 to 1 ❑ > 1'
South N/A Yes No No Visible/Fine Layer 34 to 1' O>1
No Visible/Fine Layer
East
West
N/A
NIA
Facade Description:
Yes No
Yes ❑ No No Visible/Fine Layer R °'
34t0
>1'
'1'
Root
Debris: "O lble /Fine Layer .[3% to 1' 0>?
Description:
Setbacks
Floor:___ Debris: No Visible/Fine Layer %to 1' '1'
Floor:___ Debris: No Visible/Fine Layer 34 to 1' > 1'
Floor.____ No Visible/Fine Layer % to 1' > 1'
Floor____ Debris: No Visible/Fine Layer 3% to? '1'
Floor.___ Debris: No Visible/Fine Layer % to 1' '1'
Comments