Block: r
zc
I Residential D
i)
ommercial Name of Building:
Lot: Mix UseD Other
# of Stories: AKA's: 3c.. 33 go
vJo4L'7J-.
Building Owner,Ma gamer t: T ephone Number. (Vl ) (~
Name: '?2> - FAX:
Address: 0 0 O —a v a,
On Site Contact:
Name: " Telephone Number.
Building Owner Management Activities
Interior Survey Performed HYes Q No
Exterior Survey Performed Yes j] No
General Clean Up ❑ Yes No Locations: G'
ACM Clean Up ❑ Yes 9 No Locations:
Air Monitoring ❑ Yes O No Locations:
Copies of All Reports and Data Requested Yes
Visual lnsoectlon Results:
Facade:
Inspected Debyis
North 0 N/A j es [] No J3No Visible/Fine Layer h to 1' 9>1'
South ❑ N/A es r] No j10 Visible/Fine Layer 36 to 1' 0>1'
East ❑ N/A J Yes D No No Visible/Fine Layer h to 1' > 1'
West ❑ NIA D No QNo Visible/Fine Layer 34 to 1
' 0>1'
Facade Description:
Roof
Debris: l v Visible /Fine =jhtol' . l>1'
Description: i kJ
Setbacks N/A(
Floor. Debris:DNo Visible/Fine Layer ❑ 34 to 1' >1'
Floor.____ Debris: L] No Visible/Fine Layer % to 1' > 1'
Floor.____ Debris: E] No Visible/Fine Layer 36 to 1' > 1'
Floor Debris: No Visible/Fine Layer % to 1' ❑ > 1'
Floor.____ Debris: [] No Visible/Fine Layer % to 1' [] > 1'
Comments