I WTC Visual Survey Form
Premise Address: 1
'3 s S ~-t- , Q~ ~„ ---
Block: Residential 0 Commercial D Name of Building:
Lot: Mix Use Other
# of Stories: t AKA's:
Building Owner/Mans ement: ) Telephone Number: ( )
Name: t~ it ~, FAX:
Address:
On Site Contact:
Name: fi e. ca_s Telephone Number: (T2-t2) 32j -Z &-o v
Building Owner Management Activities
Interior Survey Performed ❑'Yes ❑ No
Exterior Survey Performed 3Yes ❑ No
General Clean Up QYes ❑ No Locations:
ACM Clean Up ❑ Yes ❑ No Locations:
Air Monitoring a -Yes ❑ No Locations:
Copies of All Reports and Data Requested 9Yes
Visual Inspection Results:
Facade:
Inspected Debris
North ❑ N/A QYes ❑ No ❑ No Visible/Fine Layer ❑%2tol" 0>1"
South ❑ N/A [3Yes ❑ No ❑ No Visible/Fine Layer ❑%2to 1" 0>1"
East ❑ N/A EYes ❑ No ❑ No Visible/Fine Layer ❑%2 to 1" 0>1"
West ❑ N/A [Yes ❑ No ❑ No Visible/Fine Layer ❑Y2to1" 0>1"
Facade Des ri ti n
t. c r
Roof
1
Debris: No Visible /Fine ayer ❑ Y2 to 1" •1 - 0 0>1"
Description:
Setbacks N/A 51
Floor. Debris: ❑ No Visible/Fine Layer ❑'/ to 1" ❑ > 1"
Floor: Debris: ❑ No Visible/Fine Layer ❑ % to 1" ❑ > 1"
Floor: Debris: ❑ No Visible/Fine Layer ❑ Y2 to 1" ❑ > 1"
Floor: Debris: ❑ No Visible/Fine Layer ❑ %2 to 1" ❑ > 1"
Floor: Debris: ❑ No Visible/Fine Layer ❑V:to 1" ❑ > 1"
Comments