WTC Visual Survey Form
Premise Address:
Ca> 33 B{., (b} / 9 7~: 1 p/
Block: Residential D Commercial p Name of Building:
Lot: Mix UseD Other
# of Stories: AKA's:
Building Owner/Management Telephone Number. ( )
Name: FAX:
Address:
On Site Contact: V. p
Name: " MapkI.p j Telephone Number. 2/t) 2S—Z9o.
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 p Yes
Visual Inspection Results:
Facade:
Inspected Debris
North ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑ % to? r] > 1'
South HYesHNo
Yes er ❑ 34 to V
East
West
Q N/A
❑ N/A
Yes No
❑ Yes ❑ No
No Visible/Fine Layery 34 to 1"
❑ No Visible/Fine Layer H] 34 to 1'
> '1
❑ > 1'
Facade Description:
Roof
Debris: ❑ No Visible /Fine Layer X% to V 0>1'
Description: rrs~ i raw
Setbacks WA
Floor. — Debris:❑ No Visible/Fine Layer M3~4 to 1' ❑ >1'
Floor. Debris: ❑ No Visible/Fine Layer % to E' ❑ > 1'
Floor. Debris: ❑ No Visible/Fine Layer 34 to? 0>1'
Floor.
Floor.
Debris: ❑ No Visible/Fine Layer
Debris: ❑ No Visible/Fine Layer
36 to ?
34b? H3.
>1'
1'