f WTC Visual Survey Form BN1* I OO10q 0
Promise Address: 1 I a ne-
I
D Ma 1 en
Block: Residential 0 Commercial J Name of Building:
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 0 No
Exterior Survey Performed ❑ Yes 0 No
General Clean Up ❑ Yes 0 No Locations:
ACM Clean Up ❑ Yes 0 No Locations:
Air Monitoring ❑ Yes 0 No Locations:
Copies of All Reports and Data Requested J Yes
Visual inspection Kesuits:
Facade:
Inspected Debris
North 0 N/A ❑ Yes 0 No ❑ No Visible/Fine Layer % to 1" 0>1 "
South 0 N/A ❑ Yes 0 No ❑ No Visible/Fine Layer v to 1" 0>1"
East [] N/A 0 Yes 0 No ❑ No Visible/Fine Layer V2 to 1" [J> 1"
West 0 N/A 0 Yes 0 No 0 No Visible/Fine Layer Va to 1" 0>1"
:ad Description:
VZQ GASA tIJG.
Roof
Debris: 0 No Visible /Fine Layer %tot" ❑>1"
Description:
Setbacks N/A ❑
Floor. Debris: 0 No Visible/Fine Layer D Y2 to 1" ❑ > 1"
Floor. Debris: 0 No Visible/Fine Layer 0 Va to 1" ❑ > 1"
Floor. Debris: 0 No Visible/Fine Layer ❑ % to 1" ❑ > 1"
Floor. Debris: 0 No Visible/Fine Layer ❑ Va to 1" ❑ > 1"
Floor Debris: 0 No Visible/Fine Layer ❑ % to 1" ❑ > 1"
Comments
C 4® 5tea. CoVol;Art~i 1MG-
Date: /02c 0/2002 Inspection by: Name: ,4 P Agency: DEP
Name: Agency:
NYC-WTC 000101924
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NYC-WTC_000101924Source: NYC Law Department, mirrored locally