WTC Visual Survey Form '$t* 1Oo I CQ (0
Premise Address: €
01-03 MaJen
Block: 4iiS Residential 0 Commercial Name of Building:
Lot Mix UseD 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 0 Yes 0 No Locations:
ACM Clean Up 0 Yes 0 No Locations:
Air Monitoring ❑ Yes 0 No Locations:
Copies of All Reports and Data Requested 0 Yes
Visual Inspection Results:
Facade:
Inspected Debris
North ❑ N/A ❑ Yes 0 No ❑ No Visible/Fine Layer JJj34 to? 0>1"
South ❑ N/A ❑Yes 0 No ❑ No Visible/Fine Layer h to 1" 0>1"
East 0 N/A ❑ Yes 0 No 0 No Visible/Fine Layer % to? 0>1"
West 0 N/A ❑ Yes 0 No ❑ No Visible/Fine Layer % to 1" [] > 1"
Facade Oescxiptign: t _ . f w _ I s _.
Debris: ❑ No Visible /Fine Layer to? 0>1"
Description:
Setbacks N/A ❑
Floor Debris: [] No Visible/Fine Layer 0 to? 0>?
Floor Debris: 0 No Visible/Fine Layer 034 to 1" 0>1"
Floor. Debris: 0 No Visible/Fine Layer ❑ % to 1" 0>?
Debris: 0 No Visible/Fine Layer 034 to 1"
Floor
Floor Debris: C] No Visible/Fine Layer 034 to 1" H >1"
>1"
I Comments
Date: Q71 'SA2002 Inspection by: Name: A P Agency: DEP
Name: Agency:
NYC-WTC 000102125
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NYC-WTC_000102125Source: NYC Law Department, mirrored locally