WTC Facade Inspection Form, DEP Box 39

NYC 9/11 Public Portal Document

0 V./ Si S-- WTC Visual Survey Form Premise Address:

Block: Residential 0 CommerctaD Name of Building Lot: Mix Use Other J U a 'c ' /o # of Stories: 0 AKA's: Building Owner/Mana ement: Telephone Number: ( ) Name: C\ 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 ❑ NIA ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑vto1" 0>1" South ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer 0%to1" 0>1" East ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer 0%to1" 0>1" West ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑%to 1" 0>1" Facade Description:

Roof `

Debris: ❑ No Visible /Fine Layer ❑ % to 1" ❑ > 1" Description: I~

Setbacks N/A ❑ Floor: Debris: ❑ No Visible/Fine Layer ❑ Va 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 ❑v to 1" ❑ > 1" Floor. Debris:[❑ No Visible/Fine Layer ❑ Y2 to 1" ❑ > 1" Comments 17 c t'-k I-c t

Date: / /2002 Inspection Team: Name: L ~— Agency: 7" Name: Agency:

NYC-WTC 000109734