Block: / Residential fJ Commercial Name of Building:
Lot: Mix Use J Other ❑
# of Stories: AKA's:
Building Owner/Management: Telephone Number: ( - /ç')
Name: FAX: ( )
Address:
On
Name: P11 Telephone Number:; P
Building owner ManagementActivities
Interior Survey Performed ❑ Yes ❑ No
Exterior Survey Performed ❑ Yes ❑ No
General Clean Up ( Yes ❑ No Locations:
ACM Clean Up ❑ YesJR'1Qo Locations:
Air Monitoring ❑ Yes No Locations:
Copies of All Reports and Data Requested Yes
Visual Inspection Results:
Facade:
Inspected Debris
North ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑ Y2 to 1" ❑ > 1"
South ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑ Y2 to 1" ❑ > 1"
East ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑ '/2 to 1" ❑ > 1"
West ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑ '/2 to 1" ❑ > 1"
Facade Description: , ()