S 11
WTC Visual Survey Form /06ISD
Premise Address:
•
Block: Residential Commercialfl Name of Building:
Lot: Mix UseD Other
# of Stories: AKA's:
Building Owner anagement: 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 RequestedD Yes
Visual inspection Results:
Facade:
Inspected Debris
North /A ❑ Yes ❑ No o Visible/Fine Layer ❑to1" ❑>1"
South
East
West
fl N/A
N/A
I N/A
Facade Description:
jJ
es ❑ No
FyIesE] No
L] Yes ❑ No
e o Visible/Fine Layer ❑%to 1" ❑> 1"
o Visible/Fine Layer ❑Atol" 0>1"
❑ No Visible/Fine Layer ❑%tol" 0>1"
Roof
Debris: No Visible !Fine Layer .❑
% to 1" ❑ > 1"
Description:
Setbacks N/A ❑
Floor Debris: No Visible/Fine Layer ❑'% to 1" ❑ > 1"
Floor. Debris: No Visible/Fine Layer ❑ % to 1" 0>1"
Floor.___ Debris: No Visible/Fine Layer % to 1" 0>1"
Floor Debris: 0 No Visible/Fine Layer % to 1" > 1"
Floor. Debris: ❑ No Visible/Fine Layer fi to 1" H>Ift