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WTC Visual Survey Form /00 / ?
Premise Address:
Block: j I
Lot:
ResidentialjJ Com rcial
Mix UseD Other
Name of Building: chidkird.
# of Stories: AKA's: 3o5- b A-( j q,-gg iu >~
Building wnegMaj3agemfnt if Telephone Number. ( )
Name: FAX:(
Address: 3o PJ fOOO7-I1D9
On Site Contact:
Name: " Telephone Number
Building Owner Management A tivities
Interior Survey Performed [ s ❑ No
Exterior Survey Perfo d s D No
General Clean Up Yes Ojirlo Locations:
ACM Clean Up Yes j,lo Locations:
Air Monitoring [] Yes13No Locations:
Copies of All Reports and Data RequestedI3Y.s
Visual InsDection Results:
Facade:
Inspected Debris
North 2'N/A Dyes 0 No o Visible/Fine Layer ?/to1" fl ,1"
South 0 N/A es [] No No Visible/Fine Layer %tot" >1"
East ❑ JlIA es H No o Visible/Fine Layer El % 0>1W
West N/A Yes No No Visible/Fine Layer []f to l"
°v ❑>1'
Facade Description:
Roof
Debris: [.~No Visible /Fine Layer ❑ r4 to V 9>?
Description:
Setbacks WA[ '
Floor. Debris:1J No Visible/Fine Layer ❑ Y to 1' 9>?
Floor. Debris: Q No Visible/Fine Layer ❑ % to 1" > 1"
Floor:____ Debris:[] No Visible/Fine Layer J Va to V > 1"
Floor: Debris: No Visible/Fine Layer % to 1' > 1"
Floor:____ Debris: No Visible/Fine Layer % to 1" H301"