WTC Visual Survev Form I(vO 02 O
P Ise Address:
g S1en 2) 1A Y
Block: } Residential 0 Commercial j 1 Name of Building:
Lots Mix UseD Other
# of Stories: 34 AKA's:
Building Owner/Management: Telephone Number. ( )
Name: FAX:
Address:
On Site Contact
Name: ' idP Telephone Number:
Building Owner Management Activi ' s
Interior Survey Performed ❑ Yes ❑ No
Exterior Survey Performed Q Yes Q No
General Clean Up ❑ Yes Q No Locations:
ACM Clean Up ❑ Yes Q No Locations:
Air Monitoring ❑ Yes Q No Locations:
Copies of All Reports and Data Requested J Yes
Visual inspection Kesuits:
Facade:
inspected Debris
North ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑%zto1" 0>1"
South ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑Yzto1" 0>1"
East ❑ N/A ❑Yes ❑ No Q No Visible/Fine Layer 0Y2to1- 0> 1-
West Q N/A Q Yes Q No ❑ No Visible/Fine Layer [3'h to 1" 0>1"
Facade Description:
Roof
Debris: 'JNo Visible /Fine Layer [J 34 to 1" ❑ > 1"
Description: &J r Ql r '- 5Ck
Setbacks N/A ❑
Floor. 24 1) et Debris h i iAcIFine Layer j9 34 to 1"
Floor: Y2 to 1"
Floor. Debris: [] No Visible/Fine Layer D 4 to 1"
Floor. C
er [ Yz to 1"
Floor. Debris: ❑ No Visible/Fine Layer Cl 34 to 1"