WTC building assessment form with facade and ACM documentation

NYC 9/11 Public Portal Document

12 ~'~'`~ WTC Visual Survey Form Premise Address' _ (~ ' aO ~, Block: y,7 Residdeent ia Commercial D I Name of Building: Lot: Mix Use fl Other # of Stories: AKA's: elep// —/2z r , Building Owner anagement~ e Number: ( Name: D~ FAX: ( D ►^ Q Address: On Site Contact: Name: • * Telephone Number: Building Owner Management Activities Interior Survey Performed TYes ❑ No Exterior Survey Performed es ❑ No General Clean Up Yes No Locations:________ 'w - ACM Clean Up ❑ Yes 2Flo Locations: Air Monitoring ❑ Yes, No Locations: Copies of All Reports and Data Requested fl Yes

Visual Inspection Results: Facade: V - Inspected Debris North h/A E Yes ❑ No ❑ No Visible/Fine Layer % to 1" ❑ > 1" South 0 N/A aYes ❑ No ❑ No Visible/Fine Layer 'A to 1" ❑ > 1" East - N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑ Y2 to 1" ❑ > 1" West ❑ N/A 2Yes ❑ No ❑ No Visible/Fine Layer 1 4 to 1" ❑ > 1" Facade Description:

Roof

• I Debris: ❑ No Visible /Fine Layer ❑'/ to 1" `g] > 1" Description: n.t• .~ ~~

Setbacks N/A ❑ Floor. Debris: 0 No Visible/Fine Layer ❑'h to 1" ❑ > 1" Floor: Debris: ❑ No Visible/Fine Layer ❑ Y: to V ❑ > 1" Floor: Debris: ❑ No Visible/Fine Layer ❑Y: to 1" ❑ > 1" Floor: Debris: ❑ No Visible/Fine Layer D to 1" ❑ > 1" Floor: Debris: ❑ No Visible/Fine Layer ❑'% to 1" ❑ > 1"

Comments

Date: / /2002 Inspection Team: Name: Agency: Name: Agency: I

NYC-WTC 000108242