Building Inspection Form, WTC Site Cleanup

NYC 9/11 Public Portal Document

WTC Visual Survey Form Premise Address:

Block: Residential EJ CommercialD Name of Building: Lot: Q Mix Use Other # of Stories: 5 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 Q Yes

Visual Inspection Results: Facade: Inspected Debris North ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑ % to 1" ❑ > 1" South Q N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer ® % to 1" ❑ > 1" East ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑ Ya to 1" ❑ > 1" West ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑ Y to 1" ❑ > 1" Facade Description: P»n .; uxb;,, L-" ~h ~✓ t S b., L t

Roof

Debris: ❑ No Visible /Fine Ayer ❑ %1t0 1" ? = ❑ > 1" 1 Description: PC- L i( ii H 11 cwl ) 9 f ► t

Setbacks N/A[] Floor: Debris: ❑ No Visible/Fine Layer ❑ Va to 1" ❑ > 1" Floor: Debris: ❑ No Visible/Fine Layer ❑ % to 1" ❑ > 1" Floor: Debris: ❑ No Visible/Fine Layer ❑ Va to 1" ❑ > 1" Floor: Debris: ❑ No Visible/Fine Layer ❑ V to 1" ❑ > 1" Floor: Debris: ❑ No Visible/Fine Layer ❑ Va to 1" ❑ > 1"

Comments Q ,

Date: 01 /~1 /2002 Inspection Team: Name: 't Agency: Name: kC, Y c►Z r Agency:

NYC-WTC 000100366