WTC inspection form for facade and setback assessment

NYC 9/11 Public Portal Document

WTC Visual Survey Form Premise Address: /\(u ~-e~~ Block: Residential) Co rcial D Name of Building: Lot: Mix Use EJ 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 0 No Exterior Survey Performed ❑ Yes 0 No General Clean Up 0 Yes 0 No Locations: ACM Clean Up 0 Yes 0 No Locations: Air Monitoring ❑ Yes 0 No Locations: Copies of All Reports and Data Requested pYes

Visual Inspection Results: Facade: Inspected Debris North ❑ N/A ❑ Yes 0 No ❑ No Visible/Fine Layer ❑Y:to1" 0>1" South ❑ N/A 0 Yes 0 No ❑ No Visible/Fine Layer ❑Ytol" 0>1" East ❑ N/A ❑ Yes O No ❑ No Visible/Fine Layer 0htol" 0>1" West ❑ N/A ❑ Yes O No ❑ No Visible/Fine Layer ❑Mato l" 0>1" Facade Description:

Roof

Debris: 0 No Visible /Fine Layer .0 Y2 to 1" 0> 1" Description:

Setbacks N/A ❑ Floor Debris: ❑ No Visible/Fine Layer ❑ 6 to 1" 0>1. Floor Debris: 0 No Visible/Fine Layer a % to 1" 0>1' Floor. Debris: 0 No Visible/Fine Layer 0 h to 1' 0>1" Floor. Debris: 0 No Visible/Fine Layer % to 1" 0> 1" Floor. Debris: 0 No Visible/Fine Layer % to 1" 0>1'

Comments

Date: 1/J 12002 Inspection Team: Name: v 'V Agency: Name: Agency: ENTERED

NYC-WTC 000100516