WTC Visual Survey Form ) 0000 Z3
Premise Address:
\ \1 .j 9
Block: Residential Commercial Name of Building:
Lot: if Mix Use 0 Other
# of Stones: AKA's:
Building Owner/Managemeot Telephone Number. ( )
Name: FAX:
Address:
On Site Contact:
Narne rOL,JL ~~~~elephone Number.
Building'Owner Management Activiti s
Interior Survey Performed 0 Yes lJNo
Exterior Survey Performed ❑ Yes 0 No
General Clean Up ❑ Yes 0 No Locations:
ACM Clean Up ❑ Yes 0 No Locations:
Air Monitoring 0 Yes 0 No Locations:
Copies of All Reports and Data Requested p Yes
Visual Inscection Results:
Facade:
Inspected Debris
North 0 N/A ❑ Yes 0 No ❑ No Visible/Fine Layer ❑i4to1' 0>1'
South ❑ N/A ❑ Yes 0 No ❑ No Visible/Fine Layer ❑ 6to 1 D>1
East ❑ N/A ❑ Yes O No ❑ No Visible/Fine Layer ❑'%to1' ❑>1'
West ❑ N/A ❑ Yes O No ❑ No Visible/Fine Layer ❑ h to 1' 0'?
Facade Description: n. (1 _
Roof
Debris: No Visible /Fine Layer []y4to1' 0>V
Description:
Setbacks N/A ,(
Floor. Debris: 0 No Visible/Fine Layer 0 % to 1' ❑ > 1'
Floor. Debris: 0 No Visible/Fine Layer ❑ y4 to 1' 0>1.
Floor. Debris: 0 No Visible/Fine Layer ❑ % to V ❑ > 1'
Floor. Debris: 0 No Visible/Fine Layer 0 % to 1' 0>1.
Floor. Debris: 0 No Visible/Fine Layer ❑ % to 1' 0>1.
Comments
Date: 1 1 12002 Inspection Team: Name: Agency:
E 1~ Name: Agency:
,3 E 0
EN i _ .CEO
NYC-WTC 000110149
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NYC-WTC_000110149Source: NYC Law Department, mirrored locally