Block: Residential 0 Commercial J Name of Building:
Lot: Mix Use J Other
# of Stories: 5 AKA's:
Building Owner/Management: Telephone Number ( )
Name: FAX:
Address: 7 ua
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 Results:
Facade:
Inspected Debris
North ❑ N/A ❑ Yes ❑ No ❑ No VSible/Fine Layer 0'/ to 1" 0>1"
South N/A Yes ❑ No 'No Visible/F4ne Layer ❑ % to 1" [3> 1"
East tj N/A Yes ❑ No No Visible/Fine Layer ❑ % to 1" [3 >1"
West ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑ / to 1" [3>1"
Facade Description:
Roof
Debris:
A No Visible /Fine-Layer ❑ Yz to 1" 0>1"
Description:
Setbacks
Floor. ( Debris: ❑ No Visible/Fine Layer ❑'/ to 1" [1> 1"
Floor. Debris: ❑ No Visible/Fine Layer ❑ % to 1" ❑ > 1"
Floor. Debris: ❑ No Visible/Fine Layer ❑ % to 1" ❑ > 1"
Floor. Debris: ❑ No VSible/Fine Layer ❑ Ya to 1" ❑ > 1"
Floor. Debris: ❑ No Visible/Fine Layer ❑'/% to 1" ❑ > 1"