Block: Residential 0 Commercial 0 Name of Building:
Lot: Mix Use f J Other
# of Stories: AKA's:
Building Owner! anagement: 0a Telephone Number. ( )
Name: IQ / FAX:
Address:
On Site Contact:
Name: ~,_. ~~ • Telephone Number: ( —
Building Owner Management Activities
Interior Survey Performed j] Yes ❑ No
Exterior Survey Performed es ❑ No
General Clean Up 9Yes D No Locations:
ACM Clean Up ❑ Yes ❑ No Locations:
Air Monitoring S'es ❑ No Locations:
Copies of All Reports and Data Requested ETfes
Visual Inspection Results:
Facade:
Inspected Debris
North ❑ N/A [l]'Yes ❑ No ❑ No Visible/Fine Layer ❑'/ to 1" ❑ > 1"
South ❑ N/A D'S(es ❑ No ❑ No Visible/Fine Layer ❑ Y2 to 1" ❑ > 1"
East ❑ N/A (des ❑ No ❑ No Visible/Fine Layer ❑ % to I" ❑ > 1"
West ❑ N/A Yes ❑ No ❑ No Visible/Fine Layer ❑ Va to 1" ❑ > 1"
Facade Description:
Roof
Debris: ❑ No Visible /Fine yer ❑ % to 1" •1 -4-* ~ ~j > 1" 1 •£"'~
Description:
J' (, k kL C
Setbacks N/A ❑
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 ❑ Y2 to 1" ❑ > 1"
Floor Debris: ❑ No Visible/Fine Layer ❑ i4 to 1" ❑ > 1"
Floor. Debris: ❑ No Visible/Fine Layer ❑ h to 1" ❑ > 1"
Comments
c .,~