NYC 9/11 Public Portal Document
WTC Visual Survey Form
Premise Address:
Block: Residential' JJ Commercial 0 Name of Building:
Lot: Mix Use ❑ 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 i - le/Fine Layer ❑ Y2 to 1" 0>1"
South ❑ N/A .'(es ❑ No o Visible/Fine Layer ❑ '/2 to 1" ❑ > 1"
East ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑ 1/ 2 to 1" ❑ > 1"
West • ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑ Y2 to 1" ❑ > 1"
Facade Description:
Roof
Debris: ❑ No Visible /Fine Layer ❑ Y2 to 1" 0>1"
Description:
Setbacks N/A
Floor: Debris: ❑ No Visible/Fine Layer ❑'/2 to 1" ❑ > 1"
Floor: Debris: ❑ No Visible/Fine Layer ❑ '/2 to 1" ❑ > 1"
Floor: Debris: ❑ No Visible/Fine Layer ❑ Y2 to 1" ❑ > 1"
Floor: Debris: ❑ No Visible/Fine Layer ❑ '/2 to 1" ❑ > 1"
Floor: Debris: ❑ No Visible/Fine Layer ❑'/2 to 1" ❑ > 1"
Comments A1
k -O G-
Date:` I —' /2002 Inspection Team: Name: ''. 'C1 CL. I`~t~mot, ,1 Agency:\ I C
Name: - r, ; i,,i l",z aW
l ~ Agency)
NYC-WTC-000112828
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