WTC Visual Survey Form Bt4 ,
10 C 1-20 q
Promise Address:
Block: iS
U9 Nassau Sfree4-
Residential El Commercial EJ Name of Building:
Lot: q 2. Mix Use 0 Other ❑
# of Stories: 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 j Yes
visual inspection Kesuits:
Facade:
Inspected Debris
North ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer Y to 1" ❑ > 1"
South ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer '/ to 1" ❑ > 1"
East ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer Y2 to 1" ❑ > 1"
West ❑ N/A El Yes ❑ No ❑ No Visible/Fine Layer Y2 to 1" ❑ > 1"
Facade Description:
Roof
Debris: ❑ No Visible /Fine Layer V% to 1" ❑ > 1"
Description:
Setbacks N/A ❑
Floor: Debris: ❑ No Visible/Fine Layer ❑ % to 1" ❑ > 1"
Floor: Debris: ❑ No Visible/Fine Layer ❑ Y2 to 1" ❑ > 1"
Floor: Debris: ❑ No Visible/Fine Layer El 1/2 to 1" ❑ > 1"
Floor: Debris: ❑ No Visible/Fine Layer ❑'/ to 1" ❑ > 1"
Floor: Debris: ❑ No Visible/Fine Layer ❑'/2 to 1" ❑ > 1"
Comments
Date: c I &b /2002 Inspection by: Name: AP Agency: D& P
Name: Agency:
NYC-WTC 000099292
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NYC-WTC_000099292Source: NYC Law Department, mirrored locally