NYC 9/11 Public Portal Document
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It WTC Survey Form /O n-7 ~
Premise Address:
Block: Residential
Rfln
CommercialD
r. Name of Building:
Lot: 7b Mix User oCiOth f - 'L-, Mrbx" ret :ii
f
# of Stories: AKA's:
Building Owner/Management: Telephone Number: (7/S) 79 7 ~7
Name: - FAX:
Address:
On Site Contact:
Name: 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 I Yes
visual Inspection Results:
Facade:
Inspected Debris
North ®N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑ %2 to 1" ❑ >1"
South 1J N/A Yes ❑ No No Visible/Fine-[ y r ❑"/to1" 0>1"
East (,IN/A HYes M No No Visible/Fine Layer ❑%to1" 0>1"
West 'N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑Y2to1" 0>1"
Facade Descfiption:
Roof
Debris: ❑ No Visible /Fine Layer ❑ % to 1" ❑ > 1"
Description: =
Setbacks N/A
Floor: Debris: ❑ No Visible/Fine Layer ❑'/ 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 ❑'/2 to 1" ❑ > 1"
Floor: Debris: ❑ No Visible/Fine Layer ❑ "/2 to 1" ❑ > 1"
Comments
Dame: A , /,/2002 Inspection Team: Name: r.. Tom_ m Agency: c2 F
ER~ 4. Name: Agency:
NYC-WTC 000114542
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