• t_ WTC Visual Survav Form
Premise Address:
~J ti -
Block: I Residential Ci Commercial Name of Building:
Lot; I Mix Use er
# of Stories: AKA's:
Building Owner an e Jment Telephone Number ( )
Name• FAX:
Address:
On Site Contact:
Name: ' ' .. S Telephone .Number
Building Owner Management Activities
Interior Survey Performed ❑ Yes fJNo
Exterior Survey Performed (] Yes No
General Clean Up DYes 9 No Locations:
ACM Clean Up 9YesDNo Locations:
Air Monitoring DYes 0 No Locations:
Copies of All Reports and Data Requested fl Ves
Visual Inspection Results:
Facade:
Inspected Debris
North ❑ NIA Yes No No Visible/Fine Layer 34 to 1' [] > 1'
South N/A Yes No No Visible/Fine Layer 44 to 1' > 1'
East N/A Yes No No Visible/Fine Layer % to 1' > Is
West N/A Yes No No Visible/Fine Layer 34 to 1' > 1'
Facade Description: n
Roof
Debris: V Visible /Fine Layer .D % to 1' 9>?
Description:
Setbacks N/A f "
Floor:___ Debris: No Visible/Fine Layer 34 to? > 1'
Floor:___ Debris: No Visible/Fine Layer 34 to 1' > 1'
Floor:____ Debris: No Visible/Fine Layer % to? > 1'
Floor:____ Debris: No Visible/Fine Layer 34 to 1' > 1'
Floor.____ Debris: No Visible/Fine Layer 34 to 1' 8301 '