A
WTC Visual Survey Form
Premise Address'
4-Z>
Block: Residential D Commercial D Name of Building:
Lot: Mix Use Other
# of Stories: AKA's:
Buildng OwnerlMaanLgement: Telephone Number. ( )
Name ~~C~ ,~. (
Address:
On Site Contact:
Name: Telephone Number: ( Zt * 3 -'
Building Owner Management Activities
Interior Survey Performed 11Yes ❑ No
Exterior Survey Performed 2Yes ❑ No
General Clean Up BYes [] No Locations:
ACM Clean Up ❑ Yes ❑ No Locations:
Air Monitoring ayes ❑ 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 ❑ % to 1" 0>1"
South ❑ N/A []'Yes ❑ No ❑ No Visible/Fine Layer ❑'/zto1" 0>1"
East ❑ N/A j es ❑ No ❑ No Visible/Fine Layer ❑%to 1" 0>1"
West ❑ N/A Yes ❑ No ❑ No Visible/Fine Layer ❑%to1" 0>1"
Facade Description:
w t-..:.
Roof
Debris: ❑ No Visible /Fine ayer ❑ .4 to 1" 1 ~"' > 1" 1 -~
Description:
` Lri+ LLtiy t
Setbacks N/A ❑
Floor: Debris: ❑ No Visible/Fine Layer ❑ Ya to 1" ❑ > 1"
Floor: Debris: ❑ No Visible/Fine Layer ❑ 1/ 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 ❑ Va to 1" ❑ > 1"
Comments ,
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