WTC Visual Survey Form
rem cress:
Block: Re idential 0 CommercialD Name of Building:
Lot: Mix UseD OtherEJ
# of Stories: AKA's:
Building OwnerlManagemen t Telephone Number. ( )
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 ❑YesDNo Locations:
Copies of All Reports and Data Requested Yes
Visual Inspection Resuits:
Facade:
Inspected Debris
North 9 N/A 9 Yes No ❑ No Visible/Fine Layer [] % to? 9)?
South N/A 1es No No Visible/Fine Layer % to? 1"
East ❑ N/A Yes No ❑ No Visible/Fine Layer 14 to 1" > 1"
West [j N/A Yes No [] No Visible/Fine Layer h to 1" > 1"
Facade Description:
Roof
Debris: o Visible /Fine Layer 936 to 1" 9>?
Description:
Setbacks N/A
Floor. Debris: No Visible/Fine Layer 4 to V >V
Floor____ Debris: No Visible/Fine Layer. 14 to? > 1"
Floor. Debris: No Visible/Fine Layer 36 to 1" > 1"
Floor Debris: No Visible/Fine Layer % to 1" >1'
Floor Debris: No Visible/Fine Layer 14 to 1" > 1"