Law Department divider sheet for WTC worksite documents

NYC 9/11 Public Portal Document

/O 77 4'o WTC Visual Survey Form 'I'I « Z 2 JPa®rrtis ddress: 7iyG 5 Block: Y11 ResidentialO Commercial Name of Building: j o 71y I Lot: Mix Use 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 ❑ 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 jJ Yes

Visual Inspection Results: Facade: Inspected Debris North ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑%to 1" 0>1" South ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑'/ to 1" 0>1" East ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer El'/ to 1" 0>1" West ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine_ Layer El'/ to 1" 0>1" Facade Description:

Roof st pj Debris: to Visible /Fine yer ❑ / to 1" .g ❑ > 1" 1 Description:

Setbacks N/A Floor. RK D b ' • ❑ No Visi'bia/F'ine La ens. ta

❑'/s to 1" r

❑ > 1" Floor Debris: 0 No Visible/Fine Layer ❑ % to 1" ❑ > 1" Floor: Debris: ❑ No Visible/Fine Layer ❑ % to 1" ❑ > 1" Floor. Debris: ❑ No Visible/Fine Layer ❑'/z to 1" ❑ > 1" Floor. Debris: ❑ No Visible/Fine Layer 014 to 1" ❑ > 1"

Comments

Date: Inspection Team: Name: Agency: Name: Agency:

NYC-WTC 000101822