Name of the owner:

Interviewee:

Designation:

Location:

Classification of the structure:

Approximate area of property (square meter):

Ownership Status Accessible to the public

Private Occupied Yes

Both Unoccupied No

Public Preservation work

in Progress

Present Use

Shrine Agriculture Entertainment Health Ecclesiastical Transportation

Monument Commerce Government Private Museum Other Specify

Residence
Landmark Education Industrial Scientific
Military

Condition Excellent Good Fair Deteriorated Ruins Unexposed

(check one) (check one)

Integrity
Altered Unaltered Moved Original Site

Describe the present and original physical appearance:

Significance

Period

Spanish Post-War

American

Specific Date of Erection: