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WTC Visual Survey Form
Premise Address:
00 3 o `11
Block: Residential 0 Commercial Name of Building:
Lot: Mix Use ❑ Other ❑
# of rtes: AKA's: P•
Building Owner/Manageme t: Telephone Number: )
Name: LLJI FAX: ( )
Address: oC
On Site Co tact:
Name: Telephone Number: P I-)) _ '5 - L
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 Results:
Facade:
Inspected Debris
North ❑ N/A es ❑ No o Visible/Fine Layer ❑ / to 1" ❑ > 1"
South ❑ N/A es ❑ No No Visible/Fine Layer ❑ / to 1" ❑ > 1"
East ❑ N/A es ❑ No o Visible/Fine Layer ❑ /Z to 1" ❑ > 1"
West ❑ N/A Fes ❑ No FNo Visible/Fine Layer ❑ % to 1" ❑ > 1"
Facade Description:
Roof
Setbacks N/A
Floor: g. Debris: No Visible/Fine Layer ❑'/ to 1"
Floor: Debris: o Visible/Fine Layer ❑ /2 to 1"
Floor: Debris: ❑ No Visible/Fine Layer ❑ / to 1"
Floor: Debris: ❑ No Visible/Fine Layer ❑ 1/ to 1"
Floor: Debris: ❑ No Visible/Fine Layer El 1/2 to 1"
WTC debris inspection form documenting visual inspection results for facade condition, ACM assessment, and building characteristics for a 3-story structure.