WTC Visual Survey Form I l)0I 1 10
P miss Address:
Block: Residential Commercial EJ Name of Building:
Lot: j. . Mix Use Other
# of Stories: AKA's:
Building Owner/Management 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 Requested J Yes
visual inspection Results:
Facade:
Inspected Debris
North ❑ N/A ❑ Yes ❑ No ❑ No Vsible/Fine Layer ❑ Yz to 1" 0>1"
South ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer E]% to 1" 0>1"
East ❑ N/A Q Yes ❑ No ❑ No Visible/Fine Layer ❑ % to 1" [J> 1"
West ❑ NIA ❑ Yes Q No ❑ No Visible/Fine Layer 034t01" 0>1"
Facade Description: _ _ A A A
Roof Wsav
Debris: ❑ No Visible /Fine yer ❑ %2 to 1" 4cif ❑ > 1"
Description:
Setbacks N/A ❑
Floor Debris: ❑ No Visible/Fine Layer ❑ 34 to 1" ❑ > 1"
Floor. Debris: ❑ No Visible/Fine Layer ❑ Va to 1" ❑ > 1"
Floor. Debris: ❑ No Visible/Fine Layer ❑ % to 1" ❑ > 1"
Floor. Debris: ❑ No Visible/Fine Layer ❑ % to 1" ❑ > 1"
Floor. Debris: Q No Visible/Fine Layer 0 34 to 1" ❑ > 1"