WTC Visual Survey Form R t4 * IDO i 11Z
Premise Address: /5 Ma i
~en kane.
Block: Residential 0 Commercial JJ Name of Building:
Lot II MixUseD 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 Q Yes Q No
General Clean Up Q Yes Q No Locations:
ACM Clean Up Q Yes 0 No Locations:
Air Monitoring ❑ Yes Q No Locations:
Copies of All Reports and Data RequestedI I Yes
Visual inspection Results:
Facade:
Inspected Debris
North Q N/A ❑ Yes ❑ No (] No Visible/Fine Layer '/ to 1" [J>?
South ❑ N/A ❑ Yes Q No Q No Visible/Fine Layer '/ to 1" 0> 1"
East ❑ N/A Q Yes Q No ❑ No Visible/Fine Layer h to 1" 0>1'
West Q N/A [] Yes Q No Q No Vsible/Fine Layer LJYa to 1" 9>1'
Facade Description:
Roof
Debris: 'o Visible /Fine Layer 0 1/a to 1" 9>1'
Description:
Setbacks N/A 0
Floor. Debris: Q No Visible/Fine Layer 0 % to 1" 0>1'
Floor Debris: Q No Visible/Fine Layer ❑ ! to 1" 0>1'
Floor Debris: 0 No Visible/Fine Layer 03: to 1" 0>1'
Floor Debris: Q No Vsible/Fine Layer. ❑ % to 1" 0>1'
Floor Debris: Q No Visible/Fine Layer ❑ 34 to 1" 9>1'
Comments
Date: 01 /,Q:)D12002 inspection by: Name: _ AP Agency: EA
Name: Agency:
NYC-WTC 000102332
OCR can misread numbers and units. Confirm readings against the page image before using them.
NYC-WTC_000102332Source: NYC Law Department, mirrored locally