WTC Visual Survey Form Io7ce9
PFeiAise Address:
/34 W sI
Block ff C Residential 0 Commercial D Name of Building:
Lot: Mix Use Other
# of Stones AKA's:
Building Owner/Management: Telephone Number. ( )
Name: FAX:
Address:
On Site Contact:
Name: - ' .. Telephone Number:
Building Owner Management Activities
Interior Survey Performed ❑ Yes 0 No
Exterior Survey Performed ❑ Yes ❑ No
General Clean Up ❑ Yes Q No Locations:
ACM Clean Up Q Yes 0 No Locations:
Air Monitoring J Yes [J No Locations:
Copies of All Reports and Data Requested Yes
Visual insDection KesultS:
Facade:
Inspected Debris
North O N/A D Yes D No' 0 No Visible/Fii~e4 r D'A to l" 0>1"
South ❑ N/A Yes ❑ No No Visible/Fir ❑%to l" 0>1"
East ON/A DYesDNo Q No Visible/Fine Layer ❑htol" 0>1"
West ❑N/A 0Yes0No ❑ No Visible/Fine Layer ❑%to l" 0>1"
Facade Description:
Roof
Debris: El No Visible !F" ❑ 6 to l" [] > 1"
Description:
Setbacks N/A 14
Floor: Debris: ❑ No Visible/Fine Layer ❑'%s to 1" ❑ > 1"
Floor Debris: 0 No Visible/Fine Layer 0 % to 1" ❑ > 1"
Floor: Debris: 0 No Visible/Fine Layer ❑ A to 1" ❑ > 1"
Floor: Debris: 0 No Visible/Fine Layer [] % to 1" ❑ > 1"
Floor. Debris: [] No Visible/Fine Layer Q'% to 1" ❑ > 1"
Comments