WTC Visual Survey Form
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Premise Address:
F .-rop s-raeer
Block: e entia1D Commercial Name of Building:
Lot: I Mix Use ❑ Oth r ❑ "
# 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 Q Yes ❑ No
General Clean Up ❑ Yes ❑ No Locations:
ACM Clean Up ❑ Yes ❑ No Locations:
Air Monitoring ❑ Yes Q No Locations:
Copies of All Reports and Data Requested ❑ Yes
Visual Inspection Results:
Facade:
Inspected qebris
North ❑ N/A ❑ Yes Q No Elill No Visible/Fine Layer ❑'/ to 1" ❑ > 1"
South ❑ N/A ❑ Yes Q No No Visible/Fine Layer ❑ Y2 to 1" ❑ > 1"
East ❑ N/A ❑ Yes Q No ljj No Visible/Fine Layer ❑ Y2 to 1" ❑ > 1"
West ❑ N/A Q Yes Q No No Visible/Fine Layer ❑ Y2 to 1" ❑ > 1"
Facade Description:
Roof
Debris: ❑ No Visible /Fine Layer X/ to 1" ❑ > 1"
Description:
Setbacks N/A ❑
Floor: Debris: ❑ No Visible/Fine Layer Q'/2 to 1" Q > 1"
Floor: Debris: Q No Visible/Fine Layer 0 1/ 2 to 1" D> 1"
Floor: Debris: Q No Visible/Fine Layer ❑ '/2 to 1" ❑ > 1"
Floor. Debris: ❑ No Visible/Fine Layer Q'/2 to 1" ❑ > 1"
Floor: Debris: ❑ No Visible/Fine Layer ❑'/2 to 1" ❑ > 1"
Comments