WTC Visual Survey Form /0®OO1
Premise Address:
q q •
Bloc • Residential 0 Commercial Name of Building:
Lot.. 1j 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 El Yes
visual inspection Results:
Facade:
Inspected Debris
North ❑ NIA ❑ Yes ❑ No ❑ No Visible/Fine Layer % to 1" C]>?
South ❑ N/A ❑ Yes ❑-No ❑ No Visible/Fine Layer !fJY2 to 1" 0>1"
East ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer % to 1" 0>1"
West ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer %2 to 1" ❑ > 1"
Facade Description:
Roof
Debris: ❑ No Visible /Fine Layer ❑Y to 1" > 1"
Description:
Setbacks N/A ❑
Floor. Debris: ❑ No Visible/Fine Layer ❑ Y 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 ❑ Y2 to 1" ❑ > 1"
Floor. Debris: []No Visible/Fine Layer ❑ 14 to 1" ❑ > 1"
Comments