Block: Residential 0 Commercial J Name of B ilding:
Lot: 013
# of Stories:
Mix Use
AKA's:
Other (_d Y
Building Owner/Management: Telephone Number. ( )
Name: FAX:
Address:
On Site Contact:
Name: • * /w- ' 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
South
East
❑ N/A
❑ N/A
®N/A
D
Yes ❑ No
Yes ❑ No
❑ Yes ❑ No
ble/Fine Layer
❑ No Visible/Fine Layer '/to1"
❑ No Visible/Fine Layer ❑%to?
jam'/to1"
❑>1"
0>1"
0>1"
West ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑Ytol" 0>1"
Facade Description:
Roof
Debris: ❑ No Visible /Fine Layer Va to 1" > 1"
Description: J_4 c mo
w.
/a
Setbacks N/A I .
Floor. Debris: ❑ No Visible/Fine Layer ❑ A to 1" ❑ > 1"
Floor. Debris: ❑ No Visible/Fine Layer D % to 1' ❑ > 1"
Floor. Debris: ❑ No Visible/Fine Layer 0'r4 to 1' ❑ > 1"
Floor. Debris: ❑ No Visible/Fine Layer ❑'/ to 1" ❑ > 1"
Floor. Debris: ❑ No Visible/Fine Layer 0 % to 1" ❑ > 1"
Checklist form documenting building characteristics, facade visual inspection results, and asbestos presence assessment at 196 Broadway for post-9/11 environmental evaluation.