WTC Visual Survey Form I O O19 I
Premise Address:
$I kA 177 , t -w-..-
Block: Residential Commercial D Name of Building:
Lot: Mix Use Other
# of Stories: AKA's: 9I1Zr
Building Owner/Managemen • Telephone Number. ( )
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 0 Yes ❑ No Locations:
Air Monitoring ❑ Yes ❑ No Locations:
Copies of All Reports and Data Requested Yes
visual Inspection Results:
Facade:
Inspected Debris
North EN/A ❑ Yes ❑ No ❑ No ViSible/Fine Layer ❑%to1" 0>1"
South ❑ N/A ® Yes ❑ No No Visibl r ❑/ato1" 0>1"
East WN/A ❑ Yes ❑ No No Visible/Fine Layer ❑ %to 1" 0>1"
West N/A ® Yes ❑ No j No Visible r ❑ Ya to 1" 0>1"
Facade Description:
Roof
Debris: No Visible ❑V to 1" ❑ > 1"
Description: 2 o AccEseE~ t~9~..~uc.M •7' (, R&,1 y
Setbacks N/A J
Floor. Debris: ❑ No Visible/Fine Layer ❑ % to 1' ❑ > 1"
Floor. Debris: ❑ No ViSible/Fine Layer fl % to 1' ❑ > 1"
Floor. Debris: ❑ No Visible/Fine Layer ❑ % to 1" ❑ > 1"
Floor. Debris: ❑ No Visible/Fine Layer 0 Y: to 1" ❑ > 1"
Floor. Debris: ❑ No Visible/Fine Layer ❑ a to 1' ❑ > 1'
Comments
Date: 4/ I o /2002 Inspection Team: Name: 2Ovr77'a)1-oh1 Agency: )6P.
ENT ERED Name: Agency:
NYC-WTC-000115010
OCR can misread numbers and units. Confirm readings against the page image before using them.
NYC-WTC_000115010Source: NYC Law Department, mirrored locally