• WTC Visual Survev Form B N ' 100 11$ ~f
Premise Address:
IH0 wt'i ii I a rr- free - q (o Fu I+on 5free-i
Block: 7'? Residential 0 Commercial Name of Building:
Lot: 20 Mix UseD 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 ❑ Yes
Visual Inspection Results:
Facade:
Inspected Debris
North ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer 11 1,4to11 ❑ > 1"
South ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer f.J % to 1" ❑ > 1"
East ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer % to 1" 0>1"
West ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer % to 1" 0>1"
Facade Des~tio K~ u~
Roof
Debris: ❑ No Vis" 1 /Fin a Y2 to 1" 0>1"
Description:
Setbacks N/A ❑
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"
Floor. Debris: ❑ No Visible/Fine Layer ❑'/ to 1" ❑ > 1"
Floor. Debris: ❑ No Visible/Fine Layer ❑ % to 1" ❑ > 1"
Comments
Date: IS) / /2002 Inspection by: Name: A? Agency: DE P
Name: Agency:
NYC-WTC 000110616
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NYC-WTC_000110616Source: NYC Law Department, mirrored locally