Block: R sidentialD Commercial Nam of B ilding
Lot: Mix Use D 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 J Yes
Visual Inspection Results:
Facade:
In ected e ris
North ❑ N/A rsflYes ❑ No o Visible/Fine Layer ❑'/to1" 0>1"
South - /A D Yes ❑ No ❑ No Visible/Fine Layer ❑ 1a to 1" 0> 1"
East ❑ N/A Yes ❑ No j to Visible/Fine Layer ❑ % to 1" ❑ > 1"
West /A 2Yes ❑ No Flo Visible/Fine Layer ❑ % to 1" 0>1'.
Facade Descripti
Roof
Debris: ❑ No Visible /Fine Layer ❑ Va to 1" D> 1"
Description:
Setbacks N/A ❑
Floor: Debris: ❑ No Visible/Fine Layer ❑ V to 1" ❑ > 1"
Floor: Debris: ❑ No Visible/Fine Layer ❑ Y to 1" ❑ > 1"
Floor: Debris: ❑ No Visible/Fine Layer ❑ Va to 1" ❑ > 1"
Floor: Debris: ❑ No Visible/Fine Layer ❑ % to 1" ❑ > 1"
Floor: Debris: ❑ No Visible/Fine Layer ❑ % to V ❑ > 1"
Comments
Date Inspection Team: Name: Agency: V
Name: Agency:
NYC-WTC 000113578
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NYC-WTC_000113578Source: NYC Law Department, mirrored locally