WTC ACM and facade damage inspection form

NYC 9/11 Public Portal Document

WTC Visual Survey Form 10 $7O Premise Address:

Block: / $ " Uside4altJ Commercial U Name of Building: Lot: 7 T~,~ Mix Use ~. # of Stories:y j AKA's: II— '4) 1011%v% Building Owner/Management: 4 - Telephone Number: ( ) Name: tI► 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 D Yes

VISUdI inspeGuvn r%rsuiw. Facade: Inspected Debris North ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer [:]'/2 to 1" 0>1" South ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer 0'/2to1" 0>1" East ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑'/2 to 1" 0>1" West ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑Y2to1" 0>1" Facade - n Description.P171 r c L€

Roof

Debris: ❑ No Visible /Fine Layer ❑'/2 to 1" •1 ❑ > 1" 1 Description:

Setbacks N/A ❑ Floor: Debris: ❑ No Visible/Fine Layer ❑ %2 to 1" ❑ > 1" Floor: Debris: ❑ No Visible/Fine Layer ❑'/2 to 1" ❑ > 1" Floor: Debris: ❑ No Visible/Fine Layer ❑ %2 to 1" ❑ > 1" Floor: Debris: ❑ No Visible/Fine Layer ❑ '/2 to 1" ❑ > 1" Floor: Debris: ❑ No Visible/Fine Layer ❑ Y2 to 1" ❑ > 1"

Date: x/9—/2002 Inspection Team: Name: Agency: Name: Agency:

NYC-WTC 000092939