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WTC Visual Survey Form t o o
IL D
Pr ise Address:
(4 D► ua e Sgrer4 -
Block: t 9) Residential J Commercial p Name of Building:
Lot: 7p t Mix Use OtherD i ' CON'o
# of S ones: 5 AKA's: ) 2 - ►"-I nz -7 A
Building Owner/Management telephone Number: ( )
Name: FAX:
Address:
On Site Contact:
Name: ' Telephone Number
Building Owner Management Activities
Interior Survey Performed ❑ Yes 0 No
Exterior Survey Performed ❑ Yes No
General Clean Up ❑ Yes 0 No Locations:
ACM Clean Up [] Yes Q No Locations:
Air Monitoring ❑ Yes ❑ No Locations:
Copies of All Reports and Data Requested Yes
Visual Inspection Results:
Facade:
Inspected Debris
North 0 N/A 0Yes ❑ No No Visible []Yto1" 0>1"
South ❑ N/A O Yes ❑ No No Visible/ ❑34to1" 0>1"
❑ N/A []Yes ❑ No
East
West ❑N/A
Facade Description:
❑Yes❑No H No Visible/Fine Layer /tot"
No Visible/Fine Layer ❑ Via to 1"
>1"
0>1"
Roof
Debris: J@ No Visible I- ]% to 1" 0>10
Description:
Setbacks N/AF
Floor. Debris: ❑ No Visible/Fine Layer [,]'/ to 1" 0>1"
Floor. Debris: ❑ No Visible/Fine Layer ❑ 34 to 1" >1"
Floor. Debris: 0 No Visible/Fine Layer 34 to 1" >1"
Floor. Debris: 0 No Visible/Fine Layer % to 1" ❑ > 1"
Floor. Debris: ❑ No Visible/Fine Layer i4 to 1" ❑ > 1"
Comments
Date: Ti 0 / 2002 Inspection Team: Name: Agency: 1)P.
N T E R E Name: Agency:
NYC-WTC-000114996
OCR can misread numbers and units. Confirm readings against the page image before using them.
NYC-WTC_000114996Source: NYC Law Department, mirrored locally
Standardized inspection checklist form for WTC-affected building documenting facade conditions, ACM presence, and debris measurements by cardinal direction.