WTC Visual Survey Form 10011;3
-Premise Address:
46 CAL~ S 7R2 'r
Block: Residential Commercial Name of Building:
Lot: Mix Use J Other
# of Stories: AKA's:
Building Owner/Management: Telephone Number: ( j i g) g 41. 7f3
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 Q Yes
Visual Inspection Results:
Facade:
Inspected Debris
North ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑ / to 1"
South ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑ % to 1"
East ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑ % to 1"
West ❑ N/A 2Yes ❑ No No Visible/Fine Layer ❑ % to 1"
Facade Description:
Roof
Debris: '/Fine Layer ❑ % to 1" 0>1"
Description: i p MI AL Gwn-J) g6.e4
Setbacks N/A,
Floor Debris: ❑ No Visible/Fine Layer ❑ % to 1" ❑ > 1"
Floor: Debris: ❑ No Visible/Fine Layer ❑ V to 1" ❑ > 1"
Floor. Debris: ❑ No Visible/Fine Layer ❑'/s to 1" ❑ > 1"
Floor: Debris: ❑ No Visible/Fine Layer ❑ Va to 1" ❑ > 1"
Floor: Debris: ❑ No Visible/Fine Layer ❑Va to 1" ❑ > 1"