Block: (® Residential j J Commercial Name of Building:
Lot: Mix UseD Other
# of Stories: 4 AKA's: -L^r--t ~,,v. s~
Building Owner/Management: Telephone Number. ( )
Name: FAX:
Address:
On Site Contact
Name: • Telephone Number:
Building Owner Management Activities
Interior Survey Performed ❑ Yes ❑ No
Exterior Survey Performed ❑ Yes D 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 p Yes
visual inspection Kesuits:
Facade:
Inspected Debris
North ❑ N/A ] Yes ❑ No ❑ No Visible/Fine Layer Q'/:to 1" 0>1'
South ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑Mato 1" 0>1"
East ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑Mato l" 0>1"
West ❑ N/A [] Yes ❑ No ❑ No Visible/Fine Layer ❑Yato1" 0>1"
Facade Description•
Roof
Debris: ❑ No Visible /Fine yer Q % to 1" ❑ > 1"
Description: ►'t2r C-r h1'c•.4 4"3 t>
Setbacks N/A Q
Floor. Debris: ❑ No Visible/Fine Layer 0 Ya to 1" 0>1"
Floor: Debris: ❑ No Visible/Fine Layer 0
V to 1" 0>1"
Floor: Debris: ❑ No Visible/Fine Layer ❑ Va to 1" ❑ > 1"
Floor. Debris: ❑ No Visible/Fine Layer ❑ %a to 1" ❑ > 1"
Floor: Debris: 0 No Visible/Fine Layer ❑ %a to 1" 0> 1"
Comments
Date: e t /-/2002 „ Inspection Team: Name: - Agency:
I Name: uc-NtZ-42. t Agency:
NYC-WTC-000115845
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NYC-WTC_000115845Source: NYC Law Department, mirrored locally