NYC 9/11 Public Portal Document
WTC Visual Survey Form
Premise Ad:a.!ess:
21
Block: ~` , Residential Commercial Name of Building:
Lot: %'( Q t' aaa ~ Mix Use Other D
# of Stories: ' AKA's: 3i
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
visuai inspecuun rwsuiis:
Facade:
Inspected Debris
North ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑'/2 to 1" ❑ > 1"
South ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑'/ to 1" ❑ > 1"
East ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑ % to 1" ❑ > 1"
West ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer E)'/2 to 1" D>1
Facade Description:
Roof
Debris: ❑ No Visible /Fine tayer ❑ % to 1" •? -~'' ❑ > 1" 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" ❑ > I"
Floor: Debris: ❑ No Visible/Fine Layer ❑ %a to 1" ❑ > 1"
Floor: Debris: ❑ No Visible/Fine Layer ❑ Va to 1" ❑ > 1"
Comments —
l~ L 1 C Z 4~s C~tS Y CC~.~S~i~ltL!, G~{ t
n/'K / iZ
(1D r-,_ , Yi jC' Q-,I /ti £.&J N 6 1`
Date: _ CI / 2.'l /2002 Inspection Team: Name: Agency:
Name: HC~..r21c~: Agency:
NYC-WTC 000113404
OCR can misread numbers and units. Confirm readings against the page image before using them.