Law Department divider sheet for WTC documents

NYC 9/11 Public Portal Document /0 777/O WTC Visual Survey Form IA -1h Pre4rilse'Address: /0 71y6 3 Block: Y11 Residential I Commercial 0 Name of Building:) o 71y a Lot: Mix Use j Other # of Stories: AKA's: Building Owner/Management: Telephone Number. ( ) Name: S 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 j Yes

Visual Inspection Results: Facade: Inspected Debris North ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑%to1" 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 ❑%to 1" 0>1" Facade Description:

Roof ►:1 Debris: j No Visible /Fine yer ❑ %2 to 1" •9 0>1" '1 Description:

Setbacks N/A Floor. r

Debris: ❑ No Visible/Fine Layer ❑ Va to 1" ❑ > 1" Floor: Debris: ❑ No Visible/Fine Layer 0 V to 1" ❑ > 1" Floor: Debris: ❑ No Visible/Fine Layer ❑'/ to 1" ❑ > 1" Floor: Debris: ❑ No Visible/Fine Layer ❑'/2 to 1" ❑ > 1" Floor: Debris: ❑ No Visible/Fine Layer ❑ Va to 1" ❑ > 1"

Comments

Date: 12002 Inspection Team: Name: t-- Agency: Name: Agency:

NYC-WTC 000101830