WTC visual survey form for residential building, 2002

►00IIO NYC 9/11 Public Portal Document

'~'~ , VVTC Vic„al survey Form Premise Address:

Block: Residential 0 Commercial L Name of Building: Lot: 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 0 Yes 0 No Exterior Survey Performed 0 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 Kesuns: Facade: Inspected Debris ❑ Yes O No No Visible/Fine Layer ❑ % to 1" 0>1" North ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑ % to 1" ❑ > 1" South 0 N/A ❑'% to 1" ❑ > 1" East ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑ % to 1" 0>1" West ❑ N/A Facade Description:

ROOT

Debris: ❑ No Visible /Fine yer ❑'/Z to 1" 0 > 1" # Description:

Setbacks N/A Floor. Debris: ❑ No Visible/Fine Layer 0 % to 1" ❑ > 1" Floor. Debris: ❑ No Visible/Fine Layer 0 % to 1" ❑ > 1" Floor: Debris: ❑ No Visible/Fine Layer ❑'A to 1" ❑ > 1" Floor: Debris: ❑ No Visible/Fine Layer ❑'/ to 1" ❑ > 1" Floor. Debris: 0 No Visible/Fine Layer ❑'/:to 1" ❑ > 1"

Comments

/—/2002 Inspection Team: Name: . t__. Agency: Date: Agency: Name:

NYC-WTC 000099927