/ Ic_7iLI O WTC Visual Survey Form
remise.,Address:
179 OU- E 5T
[188lock: Residential 0 Commercial p Name of Building:
Lot: 7S0 2.. Mix Use2j Other
# of Stories: 5 AKA's:
Building Owner/Management: Telephone Number: ( )
Name: FAX:
Address: 1 QU
On Site Contact:
Name: ' ' i_ e Telephone Number: ( )
Building Owner Managemeift 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 Visible/Fine Layer ❑'/ to l" 0>1"
South N/A Yes No No Visible/Finetyer ❑vatol" 0>1"
East N/A DYesDNo No Visible/Fine Layer ❑ % to 1" 0>1"
West ❑ N/A ❑Yes ❑ No ❑ No Visible/Fine Layer ❑'%to l" 0>1"
Facade Description: