WTC Visual Survev Form " (00!bOq
Premise Address:
Bloc Residential p Commercial Name of Building:
Lot: Mix Use j Other
# of Stories: ç AKA's:
Building Owner/Management Telephone Number. ( )
Name: FAX:
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 (E Yes ❑ No No Visible ❑'/ to 1" ❑ > 1"
South ❑ N/A []('Yes ❑ No No Visible/Fic ❑ / to 1" ❑ > 1"
East JO NIA ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑'/z to 1" 0>1"
West NIA [J Yes ❑ No ❑ No Visible/Fine Layer 0'/Z to 1" 0>1"
Facade Description:
Roof
Debris: fa No Visible ❑'/x to 1" ❑ > 1"
Description: At-r -f*;rr, & ! 7 ilJa44J. si
Setbacks N/Ag]
Floor: Debris: ❑ No Visible/Fine Layer fl 1/2 to 1" ❑ > 1"
Floor. Debris: ❑ No Visible/Fine Layer ❑'/ to 1" ❑ > 1"
Floor. Debris: ❑ No Visible/Fine Layer ❑'/ to 1" ❑ > 1"
Floor: Debris: ❑ No Visible/Fine Layer ❑'h to 1" ❑ > 1"
Floor. Debris: ❑ No Visible/Fine Layer ❑'/2 to 1" ❑ > 1"
Comments