NYC 9/11 Public Portal Document
VENTILATION SYSTEM EVALUATION FORM
Please complete this form in accordance with instructions in the accompanying guidance document
Part 1.0 General Inf r ation
')ate of eva1uati0n Jo 3 I Building contact name and phone:
Evaluation team (list name ana affiliation):
(Environmental professional)
`moo _ f c-'- uS' iz (HVACprofessional)
;Milding address: Type of Facility (check all that apply):
w A J2 .T VResidential
~,,-1 7o (L Multi-use
Other (describe)
Date of construction:
Number of residential units: Number of floors:
Prior inspection report/maintenance records available for review?:
Other comments
Ventilation system types (check all that apply and indicate total no. of units)
I Central ventilation system Mechanical exhaust system
Est. no. of units Est. no. of units 1
Mechanical make-up air system Passive shaft/duct
Est. no. of units Est, no. of units
Other (describe)
I certify that to the best of my knowledge, 'the information and observations recorded on this form
including all attachmentsyare a true and accurate representation of site conditions.
Ventil io v to AC) Evaluator Date
21y 03
Pa isual nspection Forms
Use the attached forms to document visual inspections. Complete the forms in accordance with
instructions in the accompanying guidance document.
NYC-WTC 000113713
OCR can misread numbers and units. Confirm readings against the page image before using them.