WTC Visual Survey Form /000 < 3<
Premise Address:
&J 33EAVCf. ST-RE£T
Block:' Residential Commercial Name of Building:
Lot: Mix UseD Other ❑ - WA - _ S'r e -r
# of Stories: 1é. AKA's:
Building Owner/Management p&a (yaw Telephone Number. (21 2)3 y n2 o
Name: ; FAX:
Address:
On Site Contact
Name: 1 rn -t . 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 Ayer ❑ Y to 1" 0>1"
South ❑ N/A ® Yes ❑ No ( No Visible/Fine Layer [1% to 1" ❑ > 1"
East ❑ N/A Yes ❑ No No Visible/Fine.1- - ❑ % to l" 0>1"
West N/A D Yes ❑ No ❑ No Visible/Fine Layer ❑ Y to 1" ❑ > 1"
Facade Description:
Roof
Debris: No Visible /Fine-LeyeF ❑ % to 1" ❑ > 1"
Description:
Setbacks N/A
Floor. Debris: ❑ No Visible/Fine Layer ❑'/2 to 1" ❑ > 1"
Floor: Debris: ❑ No Visible/Fine Layer ❑'/2 to 1" ❑> I
Floor. Debris: ❑ No Visible/Fine Layer ❑'/2 to 1" ❑ > 1"
Floor: Debris: ❑ No Visible/Fine Layer ❑'/2 to 1 ❑ > 1"
Floor: Debris: ❑ No Visible/Fine Layer ❑'/2 to 1" ❑ > 1"