WTC Visual Survey Form
Premise Address: I c_ l
3 cd-
Block: Residential Commercial Name of Building:
Lot: Mix Use 0 Other
# of Stories: AKA's: ea
Building Owner/Management Telephone Number. ( )
Name: FAX:
Address:
On Site Contact:
Name: - * Ntou Telephone Number.
Building Owner Management Activities
Interior Survey Performed ❑ Yes ❑ No
Exterior Survey Performed 0 Yes 0 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 inspection Kesults:
Facade:
Inspected Ogbris
North ❑ N/A s ❑ No No Visible/Fine Layer 93410 1' 9>1'
South ❑ N/A TJYesDNo ❑ No VSible/Fine Layer ❑Vzto 1" 0>1'
East ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑ % to 1" 0>1'
West ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer 0%to1" 0>1"
Facade Description:
Setbacks N/A❑
Floor. Debris: 0 No Visible/Fine Layer ❑'h to V ❑ > 1"
Floor Debris: 0 No Visible/Fine Layer ❑ % to 1" 0> 1"
Floor. Debris: 0 No Visible/Fine Layer ❑ % to 1" ❑ > 1"
Floor Debris: ❑ No Visible/Fine Layer ❑ % to T ❑ >V
Floor. Debris: ❑ No Visible/Fine Layer ❑ % to V ❑ > 1"
Comments
at E/ 02 Inspection Team: Name: C zk._ Agency:
Name: Agency:
NYC-WTC-000114456
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NYC-WTC_000114456Source: NYC Law Department, mirrored locally