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WTC Visual Survey Form 1000 c7 '~ v
Premise Address:
2- 2 c A V &R c 7—R aE'7
Block: 1 Residential 0 Commercial 0 Name of Building:
Lot: Mix Use 0 Other
# of Stories: AKA's:
Building Owner/Management: V+ RvEruS Lvc. Telephone Number: (2/2. )4 -47
Name: ru 5, , . i3Ic FAX:
Address: z e✓ iv /c tr0 4i
On Site Contact:
Name: J)e nn s: L/ raAC -09 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 (Z No Locations:
Copies of All Reports and Data Requested Yes
visuai inspection Kesuits:
Facade:
Inspected Debris
North ❑ N/A Yes ❑ No No Visible/Fine Layer 0 1/ 2 t0 1" 0>1"
South ❑ N/A Yes ❑ No No Visible/Bayer ❑'/ to 1" ❑ > 1"
East ® N/A D Yes ❑ No ❑ No Visible/Fine Layer ❑'/ to 1" ❑ > 1"
West 0
N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑'/ to 1" ❑ > 1"
Facade Description:
I Roof
Debris: 1f No Visible /Fine Layer ❑%to 1" 0>1"
Description:
Setbacks N/Ar
Floor. Debris: ❑ No Visible/Fine Layer ❑'/ to 1" ❑ > 1"
Floor: Debris: ❑ No VSible/Fine Layer ❑'/ to 1" ❑ > 1"
Floor: Debris: ❑ No Visible/Fine Layer ❑ Y% to 1' ❑ > 1"
Floor: Debris: ❑ No Visible/Fine Layer ❑'% to 1" ❑ > 1"
Floor: Debris: ❑ No Visible/Fine Layer ❑ % to 1" ❑ > 1"
WTC debris inspection form documenting visual inspection results for facade condition, ACM assessment, and building characteristics for a 3-story structure.