WTC building inspection form for residential or commercial site, 2002

NYC 9/11 Public Portal Document

WTC Visual Survey Form ( 00 1 10 5, Premise Address: /

Block: Residential 0 Commercial j 1 Name of Building: Lot: Mix Use ❑ Other ❑ # of Storie : AKA's: Building Owner/Management: Telephone Number: ( ) Name: 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 Yes

Visual Inspection Results: Facade: Inspected Debris North ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑ Yz to 1" ❑ > 1" South ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑ % to 1" ❑ > 1" East ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑ % to 1" ❑ > 1" West ❑ N/A ❑ Yes ❑ No ❑ No Visible/FinennLayer ❑ % to 1" [J>1" Facade Description: OALO

Roof prJ~~ > 1" I Debris: ❑ No Visible /Fine i.ayer ❑'/ to 1" .1 : ❑ Description:

Setbacks N/A ❑ Floor. Debris: ❑ No Visible/Fine Layer ❑ Y to 1" ❑ > 1" Floor. Debris: ❑ No Visible/Fine Layer ❑ Vz to 1" ❑ > 1" Floor: Debris: ❑ No Visible/Fine Layer ❑ % to 1" ❑ > 1" Floor: Debris: ❑ No Visible/Fine Layer ❑ % to 1" ❑ > 1" Floor: Debris: ❑ No Visible/Fine Layer ❑ % to 1" ❑ > 1"

Comments CCQjy& uko `-

Date: /V /2002 Inspection Team: Name: Agency: Name: Agency:

NYC-WTC 000094434