7
WTC Visual Survey Form
Premise Address:
9 Che4.1bQ-Y rzeaF
Block: Residential U Commercial J Name of Building:
Lot: Mix Use 1 Other
# of Stories: AKA's:
Building Owner/Management: /20 Park ra'. fj Telephone Number: (7/B )~ •9 —ca•/ 7
Name: f}14/ 17 • >r FAX:
Address:
On Site Contact:
Name: ke"r f1 ,jQ'bs Tei+a..h Telephone Number: 21 Z Z Z7-3'4
Building Owner Management Activities
Interior Survey Performed ❑ Yes 0 No
Exterior Survey Performed 0 Yes 0 No
General Clean Up ®Yes ❑ No Locations: SN Apt 3 r -'-"c cW _
ACM Clean Up 0 Yes 0 No Locations:
Air Monitoring 0 Yes 0 No Locations:
Copies of All Reports and Data Requested DYes
visual inspection rcesuits:
Facade:
Inspected Debris
North 0 N/A ®'Yes 0 No [g( No Visible/Fine Layer 04 to 1" 0> 1"
South ❑ N/A ❑ Yes 0 No ((~] No Visible/Fine Layer ❑'/ to 1" ❑ > 1"
East ON/A ❑YesDNo O No Visible/Fine Layer 0 "4 to 1" ❑ > 1"
West ON/A ❑YesDNo O No Visible/Fine Layer ❑ 34 to 1" ❑ > 1"
Facade Description:
Roof
Debris: fi 4sible•/Fine Layer ®Y: to 1" 0>1"
Description: Al--A Like t'4rns e v 4 vi M' ç ,
L d / Jbr+ c .
Setbacks NAP
Floor. Debris: 0 No Visible/Fine Layer ❑ % to 1" 0> 1"
Floor: Debris: 0 No Visible/Fine Layer ❑ % to? ❑ > 1"
Floor:
Floor:
Floor.
Debris: 0 No Visible/Fine Layer
Debris: 0 No Visible/Fine Layer 03
% to 1"
to 1"
Debris: 0 No Visible/Fine Layer 0 Y: to V
0>?
❑ > 1"
❑ > 1"