WTC Visual Survey Form
Premise Address:
-- s O Li c
Block: Res dential 0 CoComfrithcial Name of Building:
Lot: Mix Use J Other
# of Stories: 'y AKA's:
Building Owner/ anag ent: Telephone Number:; -
Name: ~~1 FAX:( P
) ---------------------
Address:
On Site Contact:
Name: '" 1 L.- Telephone Number:
Building Owner Management Activities
Interior Survey Performed ❑ Yes N
Exterior Survey Performed ❑ Yes çNo
General Clean Up es ❑ No Locations:
ACM Clean Up D YesNJo Locations:
Air Monitoring ❑ Yes No Locations:
Copies of All Reports and Data Requested D Yes
Visual Inspection Results:
Facade:
Inspected Debris
North ..- N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑Mato l" ❑> 1"
South N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑%to1" ❑>1"
East U N/A &Yes ❑ No - No Visible/Fine Layer ❑%to1" ❑>1"
West ❑ N/A Yes ❑ No [-No Visible/Fine Layer ❑%to1" ❑>1"
Facade Description:
Roof
Debris: o Visible /Fine yer ❑ 1/2 to 1" '1
;'L > •1 t-1.
❑ 1"
Description:
Setbacks N/A
Floor: Debris: ❑ No Visible/Fine Layer ❑ Va to 1" ❑ > 1"
Floor: Debris: ❑ No Visible/Fine Layer ❑ 34 to 1" ❑ > 1"
Floor: Debris: ❑ No Visible/Fine Layer ❑ Va to 1" ❑ > 1"
Floor: Debris: ❑ No Visible/Fine Layer ❑ Va to 1" ❑ > 1"
Floor: Debris: ❑ No Visible/Fine Layer 034 to 1" ❑ > 1"