WTC Asbestos Inspection Form, BINs 1001418-19

NYC 9/11 Public Portal Document

WTC Visual Survey Form (C) Premise Address:

Block: Residential 0 Commercial J tjame of Building: Lot: Mix Use ❑ 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 ❑ Yes ❑ No General Clean Up ❑ Yes ❑ No Locations: ACM Clean Up ❑ Yes ❑ No Locations: Air Monitoring ❑ Yes ❑ No Locations: Copies of All Reports and Data Requested J Yes Visual Inspection Results: Facade: Inspected Debris North ❑ N/A ❑ Yes ❑ No ❑ No ViSible/Fine Layer ❑%to1" 0>1" South ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑Mato 1" 0>1" East ❑ N/A ❑ Yes ❑ No ❑ No VSible/Fine Layer ❑Vato1" 0>1" West ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑%to1" ❑>1" Facade Description: Lei

Roof

Debris: No Visible /Fine dyer ❑ % to 1" ? =~"''~ ❑ > 1" ` Description:

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

Comments

Date: Inspection Team: Name: Agency: Name: Agency:

NYC-WTC 000109608