Block: Residential 0 Commercial Name of Building:
Lot: Mix Use f 1 Other
# of Stories: AKA's:
Building Owner/Management: ; ' mr vM m=u;Telephone Number: ( )
Name: t FAX:
Address:
On Site Contact:
Name: Telephone Number:
Building Owner Management Activities
Interior Survey Performed ❑ Yes Q No
Exterior Survey Performed [] Yes Q No
General Clean Up Q Yes Q No Locations:
ACM Clean Up Q Yes Q No Locations:
Air Monitoring ❑ Yes Q No Locations:
Copies of All Reports and Data Requested EYes
Visual Inspection Results:
Facade:
Inspected Debris
North ❑ N/A [] Yes Q No ❑ No Visible/Fine Layer Q'/to1" 0>1"
South N/A Yes Q No No Visible/F-ue-Layer ❑'/to1" 0>1"
East N/A Yes Q No No Visible/Fine Layer ❑'/:to 1'" 0>1"
West N/A 0YesQNo No Visible/Fine Layer ❑%:to 1" ❑> 1"
Facade Description:
Roof
Debris: Q No Visible /Fine Layer X Y to 1" 0> 1"
Description: r.~, -4..~ ~►.I. ~2 . nle ed ate
Setbacks N/A
Floor. Debris: Q No Visible/Fine Layer Q% to 1" ❑ > 1"
Floor: Debris: Q No Visible/Fine Layer Q % to 1" ❑ > 1"
Floor: Debris: Q No Visible/Fine Layer ❑'% to 1" ❑ > 1"
Floor: Debris: Q No Visible/Fine Layer ❑'/ to 1" 0> 1"
Floor: Debris: Q No Visible/Fine Layer 0 % to 1" ❑ > 1"
Comments