NYC 9/11 Public Portal Document
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WTC Visual Survey Form
Premise Address:
PLct?V tóM
Block: Residential Com cial Name of Building:
Lot: 4.Mix UseD Other
# of Stories: AKA's:
Building Own Manageçnen • , Telephone Number: ( )
Name: K / ~-c I FAX:
Address:
On Site Contact:
Name: " Telephone Number:
Building Owner Management Activities
Interior Survey Performed 0 Yes ❑ No
Exterior Survey Performed ❑ Yes ❑ No
General Clean Up 0 Yes ❑ No Locations:
ACM Clean Up ❑ Yes ❑ No Locations:
Air Monitoring ❑ Yes ❑ No Locations:
Copies of All Reports and Data Requested fl Yes
Visual Inspection Results:
Facade:
Inspected Debris
North ❑ N/A ❑ Yes D No ❑ No Visible/Fine Layer Q 1Ato 1" 0>1"
S
South ❑ N/A. ❑YesQNo ❑ No Visible/Fine Layer ❑'Atol" 0>1"
East ❑ N/A ❑YesQNo ❑ No Visible/Fine Layer ❑%tol" 0>1"
West ❑ N/A []YesQNo ❑ No Visible/Fine Layer ❑Y,to l" 0>1"
( r Facade Description:
IS C
Roof
Debris: CNo Visible /Fine Layer ❑ 1/2 to 1" , ❑ > 1"
Description:
Setbacks
Floor. Debris: ❑ No Visible/Fine Layer 0'4 to 1' 0>1"
Floor. Debris: 0 No Visible/Fine Layer ❑ % to 1' 0>1"
Floor: Debris: 0 No Visible/Fine Layer ❑ Y: to 1" ❑ > 1"
• Floor. Debris: 0 No Visible/Fine Layer ❑ 4 to 1" 0>?
• Floor. Debris: ❑ No Visible/Fine Layer ❑ 4 to 1" ❑ > 1"
Comments
R En
r
Date: If/t~902 Inspection Team: Name: Agency:
Name: Agency:
NYC-WTC 000110136
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