___. WTI Visual Survey Form
Premise Address:
as;
Block: 101 ResidentiallJ Commercial Name of Building:
Lot Mix Use 9 Other
# of Stories: AKA's:
Building OwnerlManagement Telephone Number.
Name: FAX:
Address:
On Site. Contact:
.
Name: Telephone Number.
Building Owner Management Activities
Interior Survey Performed Yes Q 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 DYes
Visual inscectfon Results:
Facade:
Ins cfied Oe ris
North iAk es No o Visible/Fine % to? > 1'
South es No o Visible/Fine Layer % to 1' >1'
East N/A Yes No No Visible/Fine Layer 34 to 1 > 1'
West N/A Yes No No Visible/Fine Layer
LayerH%tol" > 1'
Facade Description: