WTC Visual Survaiv Fnrm /v8 a6o~ V
erP mise Address: F
~— JE-
Block: Residential 0 LComrnerclarç Name of Building:
Lot Mixusefl Other
# of Stories: AKA's:
Building Owner/Mana ement: Telephone Number: ( )
Name: < Ts+ -ç4 - LL.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 Q Yes D No Locations:
Copies of All Reports and Data Requested Yes
Visual Insoection Results:
Facade:
Inspected Debris
North ❑ N/A DYesDNo No Visible/Fine Layer 1J 3 to 10 0>1-
South N/A Yes No No Visible/Fine Layer % to 1' 30 1 0
East N/A Yes No No Visible/Fine Layer 4to1 D>r
West N/A Hygs No No Visible/Fine Layer 34 to 1 0>?
Facade Description: 11 ()