WTC Visual Survey Form too t C,flOC)
Premise Address:
Block: Residential LI Commercial Name of Building:
Lot: Mix Use Other — JOs i asTfc .
# of Stories: 5 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 BYes ❑ No No Visible/F dyer ❑'/ to 1" ❑ > 1"
South ❑ N/A S Yes ❑ No No Visible/)< -___❑ % to 1" 0>1"
East ®N/A ❑ Yes E] No ❑ No Vsible/Fine Layer ❑ % to 1" 0>1"
West ['N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑ Y2 to 1" ❑ > 1"
Facade Description:
Roof
Debris: No Visible ❑ h to 1" ❑ > 1"
Description:
Setbacks N/A j
Floor. Debris: ❑ No Visible/Fine Layer ❑'h to 1" ❑ > 1"
Floor: Debris: ❑ No Visible/Fine Layer ❑'/2 to 1" ❑ > 1"
Floor. Debris: ❑ No Visible/Fine Layer ❑'/2 to 1" ❑ > 1"
Floor: Debris: ❑ No Visible/Fine Layer ❑ 1/ 2 to 1" ❑ > 1"
Floor: Debris: ❑ No Visible/Fine Layer El /2 to 1" ❑ > 1"