WTC Visual Survev Form
ir tnise Address: t ~ c ,i
G
Block: Residential CommerciaP . Name of Building:
Lot: Imix imarlOther fl
# of Stories: AKA's:
Building Own !Management: Telephone Number. ( )
Name: FAX:
Address:
On Site Contact
Name: ' p b tL Telephone Number
Building Owner Management Activities
Interior Survey Performed 1Yes No
Exterior Survey Performed Q Yes 8 No
General Clean Up 0 Yes 0 No Locations:
ACM Clean Up Q Yes ❑ No Locations:
Air Monitoring 9 Yes[] No Locations:
Copies of All Reports and Data Requested Yes
Visual inspection Results:
Facade:
In ected Debris
North ❑ N/A No No Visible/Fine Layer h to 1' 0>?
Q Yes ❑ No 0>1'
South
East
West
/A
/A
A
Q Yes Q No
t] Yes Q No
R No Visible/Fine Layer 34to 1'
No Visible/Fine Layer OVatol'
j] No Visible/Fine Layer QYato1'
0>1'
0>1'
Facade Description:
Roof
Debris: j No Visible /Fine Layer .[] 34 to 1' [] > V
Description:
Setbacks N/A Q
Floor Debris: ❑ No Visible/Fine Layer ❑ 34 to V 0>1.
Floor. Debris: No Visible/Fine Layer ❑ 34 to V > 1'
Floor. Debris: H No Visible/Fine Layer 034101. > 1'
Floor. Debris: No Visible/Fine Layer 934 to 1' 0> 1'
Floor. Debris: H No Visible/Fine Layer ❑ 34 to 1' tJ> 1'
Comments