WTC Visual Survey Form J Q Q 0I"7 f
Premise Address: 1 . S
Block: 3 Residential 0 Commercial p Name of Building:
Lot: G Mix Use 0 Other
# of Stori s: AKA's:
Building Owner/Management Telephone Number. ( )
Name: FAX:(
Address:
On Site Contact ,
Name: " t ~' G ta¢ b
Telephone Number
Building Owner Management
Interior Survey Performed ❑ActivM
Ys O
Exterior Survey Performed es [j No
General Clean Up [] Yes DNo Locations:
ACM Clean Up ❑ Yes~o Locations:
Air Monitoring ❑ Yes o Locations:
Copies of All Reports and Data Requested Yes
Visual Inspection Results:
Facade:
Inspected ~De~b s
North [941/A [ 'es 0 No No Visible/Fine Layer ❑ % to 1" 0> 1"
South 9-N/A es ❑ No 9No Visible/Fine Layer ❑ % to 1" 0>1"
East 941/A s ❑ No 1"o Visible/Fine Layer ❑ Va to 1" 9> 1"
West [] N/A jJYes ❑ No Q-N Visible/Fine Layer [J a to 1" 0>1"
Facade Description:
Roof
Debris: to Visible /Fine Layer ❑ % to 1" 9>1"
Description:
Setbacks N/A 0
Floor. Debris: Q No Visible/Fine Layer ❑ % to 1" 0>1"
Floor. Debris: Q No Visible/Fine Layer ❑ % to 1" 9>1"
Floor Debris: ❑ No Visible/Fine Layer [] %a to 1" 9>1"
Floor Debris: [j No Visible/Fine Layer ❑ h to 1" 0>1"
Floor. Debris: j] No Visible/Fine Layer [J 34 to 1" j]>1"
Comments
P11
'Aroolcl%AA r.4_\r 1t Z.
-<r
Inspection Team: Name: Agency: VJ (
Name: Agency:
NYC-WTC-000115380
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NYC-WTC_000115380Source: NYC Law Department, mirrored locally