Block: Residential D Commercial 0 Name of Building:
Lot: Mix Use J Other
# of Stories: AKA's:
Building Owner/Management: n Telephone Number: ( )
Name: c= FAX:
Address:
On Site Contact:
Name: c,,,,. Z 0 Telephone Number: (Zt 3 2_i
Building Owner Management Activities
Interior Survey Performed D Yes 0 No
Exterior Survey Performed Yes ❑ No
General Clean Up 9Yes [] No Locations:
ACM Clean Up ❑ Yes ❑ No Locations:
Air Monitoring ❑'Sres ❑ No Locations:
Copies of All Reports and Data Requested es
Visual inspection Results:
Facade:
Inspected Debris
North ❑ N/A ['Yes ❑ No ❑ No Visible/Fine Layer ❑'h to 1" 0>1"
South ❑ N/A D'S'es ❑ No ❑ No Visible/Fine Layer ❑%to 1" 0>1"
East ❑ N/A ''es ❑ No ❑ No Visible/Fine Layer ❑%to 1" O>1
West ❑ N/A 11JS'es ❑ No ❑ No Visible/Fine Layer ❑'/to1" 0>1"
Facade Description:
eh
Roof
Debris: ❑ No Visible /Fine ayer ❑'/ to 1" '1 •t "'d > 1" ./ •~ ''~
Description:
'M
Setbacks N/A ❑
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 ❑ % to 1" ❑ > 1"
Floor: Debris: ❑ No Visible/Fine Layer ❑ V to 1" ❑ > 1"
Comments
G
_________
,k' i t- - c