Premise Address: ns
WTC Visual Survey Form t001 q o
maiden kane_
Block: 0
Residential Commercial 0 I
Name of Building:
Lot Mix Use Other
# of Sto es: AKA's:
Building Owner/Management Telephone Number. ( )
Name: FAX:
Address:
On Site Contact:
Name: Telephone Number.
Building Owner Management Activities
Interior Survey Performed ❑ Yes Q No
Exterior Survey Performed ❑ Yes Q No
General Clean Up ❑ Yes Q No Locations:
ACM Clean Up ❑ Yes Q No Locations:
Air Monitoring ❑ Yes Q No Locations:
Copies of All Reports and Data Requested J Yes
Visual Inspection Results:
Facade:
Inspected Debris
North ❑ N/A ❑ Yes Q No Q No Visible/Fine Layer to 1" 0>1"
South ❑ N/A ❑ Yes Q No ❑ No Visible/Fine Layer / to 1" 9>1
East ❑ N/A ❑ Yes Q No ❑ No Visible/Fine Layer a to 1" 0>1"
West ❑NIA Q Yes ❑ No ❑ No Visible/Fine Layer V to 1" 0>1"
Facade Description:
Roof
Debris: Q No Visible /Fine Layer to? ❑>1"
Description:
Setbacks N/A ❑
Floor. Debris: Q No Visible/Fine Layer 0 % to 1" ❑ > 1"
Floor Debris: Q No Visible/Fine Layer Q % to 1" 0>1"
Floor____ Debris: Q No Visible/Fine Layer ❑ % to 1" 0>1"
Floor Debris: Q No Visible/Fine Layer 0 Va to 1" 0>1"
Floor Debris: Q No Visible/Fine Layer 0 % to 1" 0>1"
Comments
Date: 01 I 1&12002,, Inspection by: Name: _A P Agency: DEP
f Name: Agency:
NYC-WTC 000102209
OCR can misread numbers and units. Confirm readings against the page image before using them.
NYC-WTC_000102209Source: NYC Law Department, mirrored locally
A building inventory and asbestos survey form for a WTC-related property, documenting structure details, facade condition by direction, and ACM locations.