Law Department divider sheet for WTC worksite documents

NYC 9/11 Public Portal Document

WTC Visual Survey Form (00/3 9~ ~ Premise Address: 3

Block: Residential Commercial Name of Builds g: 7 MP&- Lot: Mix Use Other # of Sto es: AKA's: Building Owner/Management: nn nn Q ~ Telephone Number ( ) Name: t rv1 c 1 CF : 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 0 No Locations: ACM Clean Up 0 Yes ❑ No Locations: Air Monitoring ❑ Yes ❑ No Locations: Copies of All Reports and Data Requested Yes

Visual Inscection Results: Facade: Inspected Debris North ❑ N/A fl YesDNo 0 No Visible/Fine Layer ❑%to 1" D>1 South ❑ N/A 9 Yes No ❑ No Visible/Fine Layer ❑ % to 1" 0>1" East N/A JYes No ❑ No Visible/Fine Layer ❑%tol" ❑>1" West N/A 0 YesE]No ❑ No Vi, ible/Fine Layer ❑Y2to1" ❑>1" Facade Description: n ~)

Roof

Debris: No Visible /Fine Layer .❑.4 to 1" ❑ > 1" Description:

Setbacks N/A Floor Debris:UNo Visible/Fine Layer U % to 1" ❑ > 1" Floor Debris: ❑ No Visible/Fine Layer ❑ % to V 9>10 Floor - Debris: ❑ No Visible/Fine Layer ❑ h to V 0>1" Floor Debris: ❑ No Visible/Fine Layer 6 to 1" >I " Floor __ Debris: ❑ No Visible/Fine Layer g % to 1" g >1"

Comments

Date: / 12002 Inspection Team: Name:_-M —.- Agency: Name: Agency: ENTERED

NYC-WTC 000101817