Block: Residential D Commercial Name of Building:
Lot: Mix Use 0 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 ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑ Va to 1" ❑ > 1"
South ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑ % to 1" ❑ > 1"
East ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑ Va to 1" ❑ > 1"
West ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑ V to 1" ❑ > 1"
Facade Description:
GL~ a 1
Roof
Debris: No Visible /Fine Layer ❑ V2 to 1" 0>?
Description:
Setbacks N/A
Floor. Debris: ❑ No Visible/Fine Layer 0
V to 1" ❑ > 1"
Floor. Debris: ❑ No Visible/Fine Layer ❑ Va to 1" ❑ > 1"
Floor: Debris: 0 No Visible/Fine Layer ❑ Va to 1" ❑ > 1"
Floor. Debris: ❑ No Visible/Fine Layer ❑'%a to 1" ❑ > 1"
Floor: Debris: ❑ No Visible/Fine Layer ❑% to 1" ❑ > 1"