WTC Visual Survey Form 100t(D5 ?
Premise Address:
3 5 0 7
Block: 5 Residential 0 Commerci lZ Name of Building:
Lot: MixUseD Other
# of S o es: AKA's:
Building Owner/Management: 6v. Telephone Number (2 t2) 297 -2.,a-
Name: FAX:
Address:
On Site Contact
Name: ele hone Number.
Building Owner Management Activitlis
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 9 No Locations:
Copies of All Reports and Data Requested Yes
Visual Inspection Results:
Facade:
Inspected Debris
North
South
East
❑NIA
❑ NIA
QN/A
❑Yes❑No
DYesDNo
Yes[JNo
❑ No Visible/Fine Layer
❑ No Visible/Fine Layer
j0 No Visible/Fine Layer
R°" 0>1"
6 to l"
to 1"
>1"
1"
West ❑ N/A DYesDNo I) No Visible/Fine Layer htol" ❑>1"
Facade Description:
Roof
Debris: No Visible /Fine Layer j] h to 1" 9>1"
Description: ,
Setbacks N/A
Floor. Debris: ❑ No Visible/Fine Layer L]'/ to 1" ❑ > 1"
Floor. Debris: ❑ No Visible/Fine Layer ❑ % to 1" ❑ >1"
Floor. Debris: [] No Visible/Fine Layer ❑ h to 1" 0>10
Floor.
Floor H
Debris: No Visible/Fine Layer
Debris: No Visible/Fine Layer
Va to 1"
% to 1" H > 1"
> 1"