53 WORTH STREET; BN# 1001958; Block: 176; Lot: 4

NYC 9/11 Public Portal Document

S WTC Visual Survey Form /Q,,, s 1 Premix A rose: Block: j71 Resldentialp Commercial Name of Building: Lot: I I Mix UseD Other g of Stories: AKA's: Building Owner a gement: Telephone Number: ( ) Name: PS 1 FAX: Address: On Site Contact Name: ' ' '' Telephone Number: Building Owner Management Activities Interior Survey Performed ❑ Yes 0 No Exterior Survey Performed a Yes 0 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 0 Yes

Visual Inspection Results: Facade: Inspected Debris North ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer i4 to 1" 0>1' South ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer %to 1' 0>1' East ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑%to 1" 0>1' West Q N/A O Yes ❑ No 0 No Visible/Fine Layer ❑ 6 to 1' 0>1' Facade Description:

Roof Debris: No Visible /Fine Layer .0 % to 1' L] > 1' Description:

Setbacks N/A Floor___ Debris: ❑ No Visible/Fine Layer ❑ % to 1' 0>1. Floor____ Debris: ❑ No Visible/Fine Layer 0 i4 to 1' 0>1' Floor.____ Debris: ❑ No Visible/Fine Layer ❑ Y4 to 1" 0>1' Floor: Debris: 0 No Visible/Fine Layer % to V > 1" Floor.____ ❑ No Visible/Fine Layer g % to 1" Hz~le

Comments

Gate: _ ' / O Inspection Team: Name:_ Agency: Name: Agency:

NYC-WTC 000111027