Asbestos inspection checklist for residential building, Oct 2001

NYC 9/11 Public Portal Document

WTC Visual Survey Form Pretnisa,Address: /o77y63 Block: Y1I Residential I Commercial 0 Name of Building: ) o 11yr6 1 Lot: I). 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 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 ❑%to1" 0>1" East ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑%to 1" 0>1" West ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑Y2 to 1" 0>1" Facade Description:

Roof

Debris: ~Jo Visible /Fine yer ❑ % to 1" .1 ❑ > 1" 1 Description:

Setbacks N/A Floor. Debris: ❑ No Visible/Fine Layer ❑ Y2 to 1" ❑ > 1" Floor: Debris: ❑ No Visible/Fine Layer ❑'/ to 1" ❑ > 1" Floor: Debris: ❑ Na Visible/Fine Layer ❑ Ya to 1" ❑ > 1" Floor: Debris: ❑ No Visible/Fine Layer ❑ '/Y to 1" ❑ > 1" Floor: Debris: ❑ No Visible/Fine Layer ❑ Yz to 1" ❑ > 1"

Comments

Date: ' /2002 Inspection Team: Name: Agency: Name: Agency:

NYC-WTC 000101826