Block: Residential 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 [j No
Exterior Survey Performed [] YesD No
General Clean Up ❑ Yes 0 No Locations:
ACM Clean Up ❑ Yes D No Locations:
Air Monitoring D YesD No Locations:
Copies of All Reports and Data Requested J j Yes
Visual Inspection Results:
Facade:
Inspected Debris
North ❑ N/A ❑ YesD No No Vsible/Fine Layer ❑ % to 1" D>1"
South [J N/A ❑ YesD No HNoVsible/Fine Layer ❑ r4 to? 0> 1"
East ❑ N/A ❑ Yes 0No No Visible/Fine Layer ❑ % to 1" 0> 1"
West N/A O Yes Q No BNoVtible/Fine Layer O Ys to l" 0>1"
Facade Description:
Setbacks N/A
Floor. Debns: U No Visiblen-ine Layer ❑ 11>1
Floor. Debris: 0 No Visible/Fine Layer 9 % to 1" > 1"
Floor: Debris: 0 No Visible/Fine Layer D% to 1" > 1"
Floor. Debris: No Visible/Fine Layer % to 1" > 1"
Floor. Debris: g No Visible/Fine Layer to 1" > 1"
Comments