Building inspection form, WTC cleanup site

NYC 9/11 Public Portal Document

WTC Visual Survey Form Premise Address: ,~

Block: 4j J R sidential D Commercial Name of Building: Lot: ) Mix Use J J Other # of Stories: AKA's: Building Owner/Management: C- 1 ' 7 t4i 4jai Telephone Mimber ( •:5- 1Y1 ) 4-. 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 0 Yes 0 No Locations: ACM Clean Up 0 Yes 0 No Locations: Air Monitoring ❑ Yes ❑ No Locations: Copies of All Reports and Data Requested D Yes

Visual Inspection Results: Facade: 1 pected Debris North N/A Wes ❑ No iio Visible/Fine Layer ❑ Va to 1" [3> 1" South Q_N/A ❑ No EJ No Visible/Fine Layer ❑'/4 to 1" ❑ > 1" East ❑ N/A Bt ❑ No Flo Visible/Fine Layer ❑ % to 1" ❑ > 1" West [, N/A ❑ Yes ❑ No fl NoVisiblelFineLayer ❑ Ya to l" 0>1" Facade Des&tption:

Roof

Debris: 'No Visible /Fine Layer ❑Vato1" ❑>1" Description: ! !i

Setbacks N/A ❑ 1 1 i Floor. Debris: 0 No Visible/Fine Layer 0 V to 1" ❑ > 1" Floor: Debris: 0 No Visible/Fine Layer 0 h to 1" ❑ > 1" Floor: Debris: ❑ No Visible/Fine Layer ❑ % to 1" ❑ > 1" Floor: Debris: ❑ No Visible/Fine Layer ❑ h to i" [3 > 1" Floor. Debris: 0 No Visible/Fine Layer 0 h to 1" ❑ > 1" Comments

Date: / 12002 Ins ion Team: Name: Agency: Name: Agency:

NYC-WTC 000099587