Visual survey form for asbestos inspection, undated

NYC 9/11 Public Portal Document

T VisualS` urvey Form.. ~ '; WC ~~ ~ O 1 D Premise Add .

Block: Residential Commercial Name of Building: Lot Mix Use Other r — •

# of Stories: AKA's: Building Owner/Management Telephone Num r ( ) Name: 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 0 No Locations: Copies of All Reports and Data Requested DYes Visual Inspection Results: Facade: Inspected Debris North ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer '/ to 1" ❑ > 1" South ❑ N/A ❑ Yes ❑•No ❑ No Visible/Fine Layer '/2 to 1" 0>1" East ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer V to l" 0>1" West ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer % to 1" ❑ > 1" Facade Description:

Roof

Debris: ❑ No Visible /Fine Layer to 1" M> 1" Description:

Setbacks N/A ❑ Floor. Debris: ❑ No Visible/Fine Layer ❑ 1/ to 1" ❑ > 1" Floor: Debris: ❑ No Visible/Fine Layer ❑ Y2 to 1" ❑ > 1" Floor. Debris: ❑ No Visible/Fine Layer ❑ % to 1" ❑ > 1" Floor Debris: ❑ No Visible/Fine Layer ❑'/ to 1" ❑ > 1" Floor. Debris: ❑ No ViSible/Fine Layer ❑ Y2 to 1" ❑ > 1" Comments

Date: _~/ /2002 Inspection by: Name: C .L _ Agency: Name: • Agency:

NYC-WTC 000102700