WTC visual Survey Form
e ress
t
•emlft__
3iok Cesidential fl Commercial Name of Building: /j
t. t: Mx Us=e ❑ 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 Perte ,- ed ❑ Yes j 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 ❑ Yes
Visual Inspection Results.
Facade:
I is acted Debos
North ❑ N/A ' es ❑ No r ' No Visible/Fine Layer V2 to 1" ❑ > 1"
South ❑ N/A Yes ❑ No j No Visible/Fine Layer Y2 to 1" [1> 1"
East ❑ N/A Yes ❑ No 1, No Visible/Fine Layer V2 to 1" [1> 1"
West ❑ N/A Yes ❑ No L No Visible/Fine Layer '/2 to 1 ❑ > 1"
Facade Description:
Roof
Debris: [_] No Visible /Fine Layer '/ to 1" ❑ > 1"
Description:
Setbacks N/A
Floor: Debris: ❑ No Visible/Fine Layer []1/ to 1" [1> 1"
Floor: Debris: ❑ No Visible/Fine Layer ❑ '/2 to 1" ❑ > 1"
Floor: Debris: ❑ No Visible/Fine Layer ❑ '/2 to 1" ❑ > 1"
Floor: Debris: ❑ No Visible/Fine Layer ❑'/2 to 1" ❑ > 1"
Floor: Debris: ❑ No Visible/Fine Layer ❑ 1/2 to 1" >V