NYC 9/11 Public Portal Document
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Please complete this form in accordance with instructions in the accompanying guidance document
Part 1 A C:Pnrrnl Tnfrrmntinn
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Date of evaluation: 1 u3 I Building contact name and hone:
Evaluation team (list name and affiliation):
' AZ. '0 THJJici ENV. (Environmental professional)
h:t5 '. =. to s ERS (HVAC professional)
Building address: Type of Facility (check all that apply):
j pv~ , Residential
t-J , - ,,J \/o!L' /..J . Multi-use
Other (describe)
Date of construction:
Number of residential units: /U Number of floors: JQ
Prior inspection report/maintenance records available for review?:
Other comments
Ventilation system types (check all that apply and indicate total no. of units)
Central ventilation system Mechanical exhaust system
Est. no. of units Est. no. of units l' -'T
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 attachments are a true and accurate representation of site conditions.
Ve on to VAC) Evaluator' Dat
2. isual Inspection Forms
Use the attached forms to document visual inspections. Complete the forms in accordance with
instructions in the accompanying guidance document.
NYC-WTC 000113925
OCR can misread numbers and units. Confirm readings against the page image before using them.