WTC Visual Survey Form
Premise Address:
c ,
Block: Residential 0 Commercial in :
Lot: Mix Use Other
$ of Stories: i AKA's: o
Building Owner/Management: f~ Telephone Number
Name: z-~' Y"L cx- 22 FAX:
Address:
On Site Contact:
Name: Y c --S - Telephone Number. (2t4 32 -2C-co
Building Owner Management Activities
Interior Survey Performed ❑'Yes ❑ No
Exterior Survey Performed ( •Yes ❑ No
General Clean Up Q'Yes ❑ No Locations:
ACM Clean Up ❑ Yes ❑ No Locations:
Air Monitoring 'Yes ❑ No Locations:
Copies of All Reports and Data Requested 3Yes
visual inspection Results:
Facade:
Inspected Debris
North ❑ N/A Q'Yes ❑ No ❑ No Visible/Fine Layer ❑'/a to l" 0>1"
South ❑ N/A [Yes ❑ No ❑ No Visible/Fine Layer ❑/ato1" 0>1"
East ❑ N/A DYes ❑ No ❑ No Visible/Fine Layer ❑ /a to l" 0>1"
West ❑ N/A Q•Yes ❑ No ❑ No Visible/Fine Layer ❑/atol" 0>1"
Facade Descr'ip rt•on.
tc i) o Pict (--• cam-,
Setbacks N/A z
Floor Debris: ❑ No Visible/Fine Layer ❑ Va to 1" ❑ > 1"
Floor. Debris: 0 No Visible/Fine Layer ❑ Va to 1" ❑ > 1"
Floor: Debris: ❑ No Visible/Fine Layer ❑'/% to 1" ❑ > 1"
Floor. Debris: ❑ No Visible/Fine Layer ❑ V to 1" ❑ > 1"
Floor. Debris: ❑ No Visible/Fine Layer ❑ a to 1" ❑ > in
Comments