WTC Visual Survey Form 1001I B4
Premise Address:
7,4A70 . Fu ..-foN S7 EVr
Block: Residential 0 Commercial D Name of Building:
Lot: Mix Use Other
# of Stories. AKA's:
Building Owner/Management S 0 L I L ✓ jW.. T. Telephone Number: (ylZ ) 26— 22-go
Name: p j , ,v 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 Yes
visual inspection Kesults:
Facade:
Inspected Debris
Yes ❑ No
North
South
East
❑ N/A
0 N/A
❑ N/A
D
Yes ❑ No
Yes ❑ No
No Visible/Fine Layer
❑ No Visible/Fine Layer
Ne-Visble/Fine Layer
❑Vato 1"
❑%to1"
❑%to 1"
0>1"
0>1"
0>1"
West (0 N/A ❑ Yes ❑ No O No Visible/Fine Layer ❑%to 1" 0>1"
Facade Description:
Roof
Debris: to No-Visible-/Fine Layer ❑ % to 1" ❑ > 1"
Description: . ec m•~ 2/ 1o Z
Setbacks N/A ❑
Floor. Debris: ❑ No Visible/Fine Layer ❑ % to 1" ❑ > 1"
Floor: Debris: ❑ No VSible/Fine Layer ❑ Va 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"