Block: Residential fl Commercial 0 Name of Building:
Lot: Mix Use ❑ 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 ❑ No
Exterior Survey Performed ❑ Yes ❑ No
General Clean Up ❑ Yes ❑ No Locations:
ACM Clean Up ❑ Yes ❑ No Locations:
Air Monitoring ❑ Yes ❑ No Locations:
Copies of All Reports and Data Requested ❑ Yes
visual inspection Kesuits:
Facade:
Inspected Debris
North ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑ % to 1" 0>1"
South ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑ % to 1" ❑>1"
East ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑ % to 1" 0>1"
West ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑ % to 1" ❑> 1"
Facade Description:
Roof
Debris: ❑ No Visible /Fine Layer ❑ Y2 to 1" ❑ > 1"
Description:
Setbacks N/A ❑
Floor: Debris: ❑ No Visible/Fine Layer ❑ Y2 to 1" ❑ > 1"
Floor: Debris: ❑ No Visible/Fine Layer ❑ Y2 to 1" ❑ > 1"
Floor: Debris: ❑ No Visible/Fine Layer ❑ 1/ to 1" ❑ > 1"
Floor: Debris: ❑ No Visible/Fine Layer ❑ Y to 1" ❑ > 1"
Floor: Debris: ❑ No Visible/Fine Layer ❑ Y2 to 1" ❑ > 1"