WTC Visual Survey Form
Premise Address:
S~
Block: Residential j Commercial Name of Building:
Lot: Mix UseD OtherD
# of Stories: AKA's:
Building Owner/Management Telephone Number. ( )
Name: FAX:
Address:
On Site Contact:
Name: ' ' V IO WG 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 0 Yes ❑ No Locations:
Copies of All Reports and Data Requested Yes
Visual Inspection Results:
Facade:
Inspected Debris
North /A ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑ % to 1" 0> 1"
South 9 N/A es ❑ No J'No Visible/Fine Layer 0 % to 1" ❑ > 1"
East E N/A 0 Yes ❑ No ❑ No Visible/Fine Layer ❑ % to 1" 0> 1"
West [N/A ❑ Yes ❑ No ❑ No Vsible/Fine Layer ❑ % to 1" E]> 1"
Facade Description:
Roof
Debris: No Visible /Fine Layer .O % to 1" ❑ > 1"
Description:/
Setbacks IN/A ❑
Floor. Debris: ❑ No Visible/Fine Layer ❑'h 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 ❑ % to 1" ❑ > 1"
Floor. Debris: ❑ No Visible/Fine Layer ❑ i4 to 1" ❑ > 1"
Comments
Date: s I I /2002 Inspection Team: Name: #4L Agency:
ame: Agency:
\I TERE.
NYC-WTC-000114474
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NYC-WTC_000114474Source: NYC Law Department, mirrored locally