Wr uai Survey Form
premise Address: ~,
1s c ,nr~Gi.,.. &~~
Block: Residential j Commercial jJ Name of Building:
Lot: MixUseD 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 0 Yes No Locations:
ACM Clean Up ❑ Yes 0 No Locations:
Air Monitoring [)Yes 0 No Locations:
Copies of All Reports and Data Requested p Yes
Visual lnscection Results:
Facade:
Inspected DerIs
North °e [YesDNo o Visibie/Fine Layer ❑34to1" 0>1"
South 1/k 9`Yes ❑ No No Visible/Fine Layer 034t01' 0>1'
East ❑N/A ❑Yes❑No No Visible/Fine Layer 34 to 1" 0>1'
West ❑ N/A [} Yes 0 No No Visible/Fine Layer to 1" 0>1'
Facade Description:
Roof
Debris: j No Visible !Fine Layer .0 % to 1" j] > 1"
Description:
Setbacks N/A 0
Floor. Debris: 0 No Visible/Fine Layer ❑ 34 to 1" 0>1'
Floor
Floor.
Floor
Debris: 0 No Visible/Fine Layer D % to 1"
Debris: 0 No Visible/Fine Layer D4 to 1"
Debris: No Visible/Fine Layer 3% to 1"
0>
> 1"
1"
> 1"
Floor.____ Debris: B No Visible/Fine Layer 34 to 1" >
B 1"
Comments
A Department of Environmental Protection form recording facade and ACM inspection results for a building at 292 Greenwich Street dated February 12, 2002.