WTC Visual Survey Form
100 1 2-s 1
Premise A OW
Block: Residential Commercial Name of Building:
Lot: Mix Use Other
# of S es: AKA's:
Building owner/Management: Telephone Number. )
Name: FAX:
Address:
On Site Contact
Name: Telephone Number.
Building Owner Management Activities
Interior Survey Performed j ) 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 Yes
Visual Inspection Results:
Facade:
Inspected Debris
North N/A [I Yes[I No ❑ No Visible/Fine Layer ❑ % to 1" 0>1"
South g N/A ❑Yes ❑ No ❑ No Visible/Fine Layer ❑'A to? ❑ > 1"
East ❑ N/A ❑Yes ❑ No ❑ No Visible/Fine Layer ❑ 6 to 1" 0>1"
West 0 N/A ❑ Yes 0 No 0 No Visible/Fine Layer 9 % to 1" 0>1"
Facade Description:
Roof
Debris: ❑ No Visible /Fine Layer ❑'% to 1" > 1"
Description:
Setbacks N/A 0
Floor Debris: ❑ No Visible/Fine Layer 0 to 1" 0>1"
Floor. Debris: 0 No Visible/Fine Layer '4 to 1" 0>1"
Floor.____ Debris: ❑ No Visible/Fine Layer % to 1" 0>1"
Floor Debris: ❑ No Visible/Fine Layer %z to 1" 0>1"
Floor Debris: D No Visible/Fine Layer D % to 1" 0>1"
Comments
Q >
Date: / 2002 Inspection by: Name: C L Agency..
Name: Agency:
NYC-WTC 000115590
OCR can misread numbers and units. Confirm readings against the page image before using them.
NYC-WTC_000115590Source: NYC Law Department, mirrored locally