Premise Address: _I
WTC Visual Survey Form
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Block: n Residential D Commercial Ii Name of Bull ing:
Lot: Mix Use 9 Other 0 v-~ f
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# of Stories: J AKA's:
Building Own r/Management: 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 0 No Locations:
ACM Clean Up ❑ Yes ❑ No Locations:
Air Monitoring ❑ Yes ❑ No Locations:
Copies of All Reports and Data Requested Yes
Visual Inspection Results:
Facade:
Inspected Debris
North ' N/A ❑Yes ❑ No ❑ No Visible/Fine Layer ❑'h to l" 0>1'
South -N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑ Ya to l' 0>1'
East ❑ N/A 'es ❑ No -—, No Visible/Fine Layer ❑ % to 1" ❑ > 1"
West }1l/A [] Yes ❑ No ❑ No Visible/Fine Layer ❑ % to 1" ❑ > 1"
Facade Description:
Roof
Debris: CKNo Visible /Fine L,~lyer ❑ % to 1~; ❑ > I"
Description: _-' \ f _ ii A
Setbacks N/A ❑
Floor. Debris: ❑ No Visible/Fine Layer 9Y to 1" ❑ > 1"
Floor. Debris: ❑ No Visible/Fine Layer ❑ h to 1" ❑ > 1"
Floor: Debris: ❑ No Visible/Fine Layer ❑ % to 1" ❑ > 1"
Floor: Debris: ❑ No Visible/Fine Layer ❑ 6 to 1" ❑ > 1"
Floor: Debris: ❑ No Visible/Fine Layer [] % to 1" ❑ > 1"
Comments