Block: t Residential 0 Commercial D
a
Name of Building:
Q Q
Lot: Mix Use ❑ Other
# of Stories: AKA's:
Building Owner/Management: lephone Number: / '2)
Name: AX: )
Address:
On Site Contact:
Name: Telephone Number: ( )
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 ❑ Yes ❑ No ❑ No Visible/Fine Layer El'/ to 1" 0>1"
South ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑%to 1" 0>1"
East ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑%x to 1" 0>1"
West ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer 0%t01" 0>1"
Facade Description:
Roof
Debris: ❑ No Visible /Fine Layer ❑'AAto1" 0>1"
Description:
Setbacks N/A ❑
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 ❑ % to 1" ❑ > 1"
Floor. Debris: ❑ No Visible/Fine Layer ❑ Y2 to 1" ❑ > 1"
Floor: Debris: ❑ No Visible/Fine Layer ❑ Y2 to 1" [3> 1"
WTC debris inspection form documenting visual inspection results for facade condition, ACM assessment, and building characteristics for a 3-story structure.