NYC 9/11 Public Portal Document
ti
t
WTC Visual Survey Form
Premise Address:
`e
Block: ResidentiaI Commercial J Name of Building:
Lot: Mix Use Other
#of Stories: fo AKA's:
Building Owner/Management: Telephone Number: ( )
Name: FAX:
Address:
On Site Contacts..
Name: P11 Tele hone Number:
Building Owner Management ctivlties
Interior Survey Performed Yes ❑ No
Exterior Survey Perfo ed es No ❑
General Clean Up s LjNo Locations:
ACM Clean Up ❑ Yes [ 4o Locations:
Air Monitoring ❑ Yes Locations:
Copies of All Reports and Data Requested J J Yes
Visual Inspection Results:
Facade:
Inspected Debris
North ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑ % to 1"
South ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑ % to 1"
East ❑ N/A es❑No o Visible/Fine Layer ❑ Va to 1"
West ❑ N/A 17 !es ❑No I Ia Visible/Fine Layer ❑ / to 1"
Facade Description:
Roof
Debris: No Visible /Fine Layer ❑ % to l" 0>1"
Description:
Setbacks N/A
Floor:
V Debris: ❑ No Visible/Fine Layer ❑'/ to 1" ❑ > 1"
Floor: Debris: ❑ No Visible/Fine Layer ❑ Va to 1" ❑ > 1"
Floor: Debris: ❑ No Visible/Fine Layer ❑ % to 1" ❑ > 1"
Floor: Debris: ❑ No Visible/Fine Layer ❑'/Y to 1" ❑ > 1"
Floor: Debris: ❑ No Visible/Fine Layer ❑ Va to 1" ❑ > 1"
Comments
Date:
3/
EN
7 0 Inspection Team: Name:
Name:
'- (I Agency:
Agency:
V
NYC-WTC- 000115450
OCR can misread numbers and units. Confirm readings against the page image before using them.