17 JOHN STREET 1001216 79/10

NYC 9/11 Public Portal Document

WTC Visual Survey Form 1 0011(I Premise Address: JU ldhn S)-reek Block: Residential D Commercial Name of Building: Lot: Mix Use D Other # of S o-ries: AKA's: Building Owner/Management: 5 ra.~v Telephone Number: (Zv Z) Yic. q— Name: / 7 et- FAX:( Address: On Site Contact: Name: ' ' _O 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 mesui s: Facade: Inspected Debris North ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑ Y2 to 1" ❑ > 1" South ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑ Y2 to 1" ❑ > 1" East ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑'/2 to 1" ❑ > 1" West ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑'/2 to 1" ❑ > 1" Facade Description:

Roof

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

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

Comments

Date: ti / /2002 Inspection Team: Name: Agency: (i h Name: Agency:

NYC-WTC 000093511