ACM inspection form, 90-92, 11-story building

NYC 9/11 Public Portal Document

WT( Vigllal Survey Form Premise Address: L) Residential 0 Commercial Q Name ofJ3 i Block: t i`` ► Lot: Mix Use E l Other ❑ 1` ') # of Stories: 11- 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 ❑ Yes

Visual Inspection Results: Facade: Inspected Debris North ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑ '/2 to 1" 0>1' ©N/A Yes ❑ No 0 No Visible/Fine Layer ❑ '/2 to 1" []>1" South ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑ %2 to 1" ❑ > 1" East 0 N/A J>1" West EJ NIA 0 Yes ❑ No 3 No Visible/Fine Layer ❑ Y to 1" Facade Description:

Roof

Debris: ❑ No Visible /Fine Layer ❑ 34 to 1" ❑ > 1" Description:

Setbacks NIA ❑ Floor: Debris: ❑ No Visible/Fine Layer ❑'/ to 1" ❑ > 1" Floor: Debris: ❑ No Visible/Fine Layer ❑ V to 1" ❑ > 1" Floor. Debris: ❑ No Visible/Fine Layer ❑ Va to 1" ❑ > 1" Debris: ❑ No Visible/Fine Layer ❑ V to 1" []> 1" Floor: Floor: Debris: ❑ No Visible/Fine Layer ❑V2 to 1" ❑ > 1"

Comments

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NYC-WTC 000109622