WTC Visual Survey Form
Premise Address: 3(0
S-
Block: Residential Commercial 0 Name of wilding:
Lot: Mix Use ❑ Other
# of Stories: AKA's:
Building Owner/Management Telephone Number. ( )
Name: FAX: ( )
Address:
On Site Contact:
Name: Telephone Number:
Building Owner Management Activities
Interior Survey Performed ❑ Yes ❑ No
Exterior Survey Performed ❑ Yes ❑ No
General Clean Up ❑ Yes ❑ No Locations:
ACM Clean Up ❑ Yes ❑ No Locations:
Air Monitoring ❑ Yes ❑ No Locations:
Copies of All Reports and Data Requested ❑ Yes
Visual Inspection Results:
Facade:
Inspected Debris
North ❑ N/A JJ Yes ❑ No No Visible/Fin®-L r 01,4to1" 0>1"
South ❑ N/A ® Yes ❑ No No Visible— *Re Layer ❑'/to1" 0>1"
East ❑ NIA ® Yes ❑ No No Visible/Fine Layer 0%to1" 0>1"
West ❑ N/A E4 Yes ❑ No No Visible/F-ne-L• r ❑%to1" 0>1"
Facade Description:
Roof
Debris: 'No Visible /Fine yer ❑%to1" 0>1"
Description:
Setbacks N/A
Floor: Debris: ❑ No Visible/Fine Layer ❑'/ to 1" ❑ > 1"
Floor: Debris: ❑ No Visible/Fine Layer ❑'/Z to 1" ❑ > 1"
Floor: Debris: ❑ No Visible/Fine Layer ❑Y2 to 1" ❑ > 1"
Floor: Debris: ❑ No Visible/Fine Layer ❑ Y2 to 1" ❑ > 1"
Floor: Debris: ❑ No Visible/Fine Layer ❑ % to 1" ❑ > 1"