WTC °Visual Survey Form
Premisg Adcress: I /
Block: z5P Residential Q Commerci N n1» of ildi g:
Lot: Mix UseD Other M Vw t'- C
# of Stories: L j AKA's:
9 Y
Building Owner1Management Telephone Number. ( )
Name: FAX:
Address:
On Site Contact:
Name: • * Telephone Number:
Building Owner Management Activities
Interior Survey Performed Q Yes Q No
Exterior Survey Performed ❑ Yes Q No
General Clean Up 0 Yes Q No Locations:
ACM Clean Up ❑ Yes Q No Locations:
Air Monitoring [] Yes QNo Locations:
Copies of All Reports and Data Requested Yes
Visual Inspection Results:
Facade:
Inspected Debris
North ❑ N/A ❑YesQNo ❑ No Visible/Fine Layer El's to 1" 0>1"
South ❑ N/A esDNo Q No Visible/Fine Layer to 1" 0>1"
East Q N/A QYesDNo ❑ No Visible/Fine Layer QY2to1" 0>1"
West ❑ N/A ` yes No 0 No VSible/Fine Layer " to1" 0>1"
Facade Description:
4'.
Roof o F 1-' f
~,,
Debris: o Visible Fine Layet L] Ybo 1" > 1" `
Description. Q w ~3 S~ k~
Setbacks N/A ❑
Floor: Debris: Q No Visible/Fine Layer 034 to 1" 0> 1"
Floor Debris: Q No Visible/Fine Layer D 6 to V 0> 1"
Floor: Debris: Q No Visible/Fine Layer 034 to 1" ❑ > V•
Floor. Debris: 0 No Visible/Fine Layer 0% to 1" 0> 1"
Floor. Debris: Q No Visible/Fine Layer 036 to 1" J> 1"
Comments
Multi-page form documenting World Trade Center contamination assessment for a residential or commercial building, including facade inspection checklist and environmental testing…