V., rmise Address:
WTC Survey Form Ia74,v3
Block: Residential Commercial Name of Building:
Lot: MixUseD Other
of Stores: AKA's:
Building Owner/Management Telephone Number. ( )
Name: GCa ic FAX:
Address:
On Site Contact
Name: " Telephone Number
Building Owner Management Activities
Interior Survey Performed ❑ Yes Q No
Exterior Survey Performed [] Yes [] No
General Clean Up ❑ Yes 0 No Locations:
ACM Clean Up 9 Yes 0 No Locations:
Air Monitoring jJ Yes ❑ No Locations:
Copies of All Reports and Data Requested Yes
Visual Inspection Results:
Facade:
tns ected Debris
es Q No ` o Visible/Fine Layer > w
North
South
East
o
9"N4k
[] N/A
EVes ❑ No
D Yes D No
~~ No Visible/Fine Layer D %to1w•
O No Visible/Fine Layer 34 to 1w
Q>1
0>10
w
West ❑N/A OYes❑No 0 No Visible/Fine Layer ❑Yato 1w 0>10
Facade Description: