-p WTC Visual Survey Form
Premise Address:
Lb —
Block: Residential 0 Commercial D Name of Building:
Lot: Mix Use D Other
# of Stories: l AKA's:
Building O er/ ement: Telephone Number: (2 - J -- v
Name: - FAX:
Address:
On Site Contact:
Name: Telephone Number:
Building Owner Management Activities
Interior Survey Performed [-des ❑ No
Exterior Survey Performed [Yes ❑ No
General Clean Up (a'l'es ❑ No Locations:
ACM Clean Up ❑ Yes ❑ No Locations:
Air Monitoring des ❑ No Locations:
Copies of All Reports and Data Requested Yes
Visual inspection Results:
Facade:
Inspected Debris
North ❑ N/A [es ❑ No ❑ No Visible/Fine Layer 0½t01" 0>1"
South ❑ N/A []'Yes ❑ No ❑ No Visible/Fine Layer ❑'/2 to 1" 0>1"
East ❑ N/A EYes ❑ No ❑ No Visible/Fine Layer ❑ % to l" 0>1"
West ❑ N/A j YesONo ❑ No Visible/Fine Layer ❑%to1" 0>1"
Facade Description:
R,,,j. . 'Lv e.4
Roof
u
Debris: ] No Visible /Fine ayer ❑ V. to 1" -1 ~^''' ❑ > 1" 1
Description:
Setbacks N/A j
Floor: Debris: ❑ No Visible/Fine Layer ❑ % to 1" ❑ > 1"
Floor: Debris: ❑ No Visible/Fine Layer ❑ % to 1" ❑ > 1"
Floor: Debris: ❑ No Visible/Fine Layer ❑ % to 1" ❑ > 1"
Floor: Debris: ❑ No Visible/Fine Layer ❑ Va to 1" ❑ > 1"
Floor: Debris: ❑ No Visible/Fine Layer ❑ %2 to 1" ❑ > 1"
Comments