WTC Visual Survey Form 13N1' (d01Z18
Prehise Address:
1 ~- -
r
uName -k
Block: l Residential 0 Commerci of Building:
Lot: t S Mix Use 0 Other
# of Stories: AKA's:
Building Owner/Management: t1 Telephone Number: ( )
Name: LL..€ L "S CAS. FAX:
Address: ''"
On Site Contact:
Name: to S 1J w~9.-,1~-, Telephone Number:
Building Owner Management Activities
Interior Survey Performed 1fes ❑ No
Exterior Survey Performed es ❑ No
General Clean Up L Yes ❑ No Locations:
ACM Clean Up es ❑ No Locations:
Air Monitoring Yes ❑ No Locations:
Copies of All Reports and Data Requested es
Visual Inspection Results:
Facade:
Inspected bris
North ❑ N/A ❑ Yes ❑ No LII Visible/Fine Layer 0%to1"
No 0>1"
South ❑ N/A ❑ Yes ❑ No No Visible/Fine Layer ❑%2 to 1" 0>1"
East ❑ NIA ❑ Yes ❑ No No Visible/Fine Layer ❑%2 to 1" 0>1"
West ❑ NIA ❑ Yes ❑ No No Visible/Fine Layer ❑'/to1" 0>1"
Facade Description: __.
Roof W 5t-
vti, '
Debris: g(No Visible /Fine ayer ❑ % to 1" •1 ~'~""{ 0>1" ,_44
Description:
Setbacks N/A1
Floor: Debris: ❑ No Visible/Fine Layer ❑ % to 1" ❑ > 1"
Floor: Debris: ❑ No Visible/Fine Layer ❑ %2 to 1" ❑ > 1"
Floor: Debris: ❑ No Visible/Fine Layer ❑ Y2 to 1" ❑ > 1"
Floor: Debris: ❑ No Visible/Fine Layer ❑'/ to 1" ❑ > 1"
Floor: Debris: 0 No Visible/Fine Layer ❑ Y2 to 1" ❑ > 1"
DEP inspection form recording building details and facade conditions (north, south, east, west sides) with damage extent measurements and ACM documentation.