•1 ~. WTC Visual Survey Form
Premise Address: Q
~—
Block: Residential 0 v~h mmerciai Name of Building:
Lot Mix UseD Other
# of Stories: AKA's:
Building ner/Manag ment Telephone Number: ( )
Name: FAX:
Address:
On Site Contact
Namd: ' ' '' Telephone .Number.
Building Owner Management Activities
Interior Survey Performed ❑ Yes Q No
Exterior Survey Performed Q Yes [] No
General Clean Up DYes No Locations:
ACM Clean Up DYes No Locations:
Air Monitoring ❑ Yes 9 No Locations:
Copies of All Reports and Data Requested Yes
Visual inspection Results:
Facade:
Inspected Debris
North ❑ N/A 9 Yes ❑ No No Visible/Fine Layer 34 to 1' > 1'
South ❑ N/A 9Yes No No Visible/Fine Layer i4 to 1' > 1'
East ❑ N/A Yes No No Visible/Fine Layer %a to 1 > 1'
West a N/A Yes No n No Visible/Fine Layer H%tol" H201W
Facade Description: 0 ~U
Root
Debris: ' No Visible /Fine Layer .Di4 to 1' 0,10
Description:
setbacks N/AIQ
Floor___ . Debris: No Visible/Fine Layer 34 to 1' > 1'
Floor:___ Debris: No Visible/Fine Layer 34 to 1' '10
Floor:___ Debris: No Visible/Fine Layer 34 to 1' >10
Floor____ Debris: No Visible/Fine Layer 34 to 1' >10
Floor____ Debris: No Visible/Fine Layer 34 to 1' '1'
Comments
MTERE