Block: Residential Commercial Name of Building:
Lot Mix UseD Other
# of Stories: AKA's:
Building Owner/Management Telephone Number: ( )
Name: FAX:
Address:
On Site Contact: , a't
Name: s ~'~R~= -2 n` Lti Telephone Number: ,x.33 7ff
Building Owner Management Activities
Interior Survey Performed ❑ Yes 0 No
Exterior Survey Performed ❑ Yes 0 No
General Clean Up ❑ Yes No Locations:
ACM Clean Up [JYes[,] No Locations:
Air Monitoring ❑ Yes 0 No Locations:
Copies of All Reports and Data Requested J Yes
Visual Inspection Results:
Facade:
Inspected Debris
North ❑ N/A DYesDNo ❑ No Visible/Fine Layer to 1" 0>1"
South 0 N/A 1 Yes 0 No No Visible/Fine Layer Va to 1" 0>1"
East ❑ N/A DYesDNo D No Visible/Fine Layer ~%to 1" 0>1"
West [] N/A ❑ Yes 0 No ❑ No Visible/Fine Layer 934 to 1" ❑ > 1"
Facade Description:
Roof
Debris: ® No Visible /Fin 0'/: to 1" 4 9>1"
Description: l
Setbacks N/A ❑
Floor. Debris: 0 No Visible/Fine Layer Q % to 1" 0> 1"
Floor. Debris: 0 No Visible/Fine Layer 34 to 1" ❑ > 1"
Floor. Debris: No Visible/Fine Layer ~] % to 1" >1
Floor. Debris:E] No ViSible/Fine Layer ❑ % to 1" > 1"
Floor. Debris: 0 No Visible/Fine Layer ❑ % to 1" 0> 1"
Comments
r• ;&.'irte +~~' n
Date: d / 77 12002 inspection Team: Name:
Name: Agency:
NYC-WTC 000115820
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NYC-WTC_000115820Source: NYC Law Department, mirrored locally