WTC Visual Survey Form
Premise Address:
~
Block: Resident' ommercial j J Name of Building:
Lot: Mix UseD OtherD
# of Stories: AKA's:
Building Owne M gment: 7 / Telephone Number:
Name: o ff^ FAX: P 11
Address: .----------------------.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-. -
On Site Contact: , AA A
Name: ' v"` Telephone Number:
Building Owner Management ctivlties
Interior Survey Performed Yes ❑ No
Exterior Survey Performed es ❑ No r
General Clean Up Yes QNo Locations: '-
ACM Clean Up Yes j No Locations:
Air Monitoring Yes ❑ No Locations:
Copies of All Reports and Data Requested Yes
Visual Inspection Results:
Facade:
I pected D brie
North ❑ N/A Yes ❑ No No Visible/Fine Layer ❑ Va to 1" ❑ > 1"
South ❑ N/A YesDNo >JNo Visible/Fine Layer ❑ Ya to 1" ❑ > 1"
East ❑ N/A Yes ❑ o Visible/Fine Layer ❑ /a to 1" ❑ > 1"
West ❑ N/A ❑ No
tYes NoVgoVisible/Fine Layer ❑ Va to 1" ❑ > 1"
Facade Description:
Roof
Debris: ND. isible /Fine Layer ❑ Va to 1" ❑ > 1"
Description:
Setbacks N/A ❑
Floor: Debris: ❑ No Visible/Fine Layer ❑ Va to 1" ❑ > 1"
Floor. Debris: ❑ No Visible/Fine Layer ❑ Va to 1" ❑ > 1"
Floor: Debris: ❑ No Visible/Fine Layer ❑ Va to 1" ❑ > 1"
Floor: Debris: ❑ No Visible/Fine Layer ❑ % to 1" ❑ > 1"
Floor: Debris: ❑ No Visible/Fine Layer 0 i4 to 1" ❑ > 1"