WTC Visual Survey Form
Premise Address: j
!z 1
Block: Residential jj Commercial I Name of Building:
Lot: I Mix Use ri Other
# of Stores: AKA's:
Building Owner/Management Telephone Nu r. ( )
Name: FAX:
Address:
On Site Contact
Name: • -¼ t 1 ni (ft ' Telephone Number: ,t33 7
Building Owner Management Activities
Interior Survey Performed [] Yes No
Exterior Survey Performed D Yes ❑ No
General Clean Up ❑ Yes 0 No Locations:
ACM Clean Up D Yes D No Locations:
Air Monitoring ❑ Yes D No Locations:
Copies of All Report. and Data Requested D Yes
Visual Insoection Results:
Facade:
Inspected Debris
North D NIA DYesDNo No Visible/Fine Layer D34to1" 0>10
South ❑ NIA Yes D No No Visible/Fine Layer %to1" [B>1"
East N/A DYesDNo No Visible/Fine Layer D34to1" B30>1"
West O N/A DYesDNo No Visible/Fine Layer 036t01" 1"
Facade Description:
Roof
Debris: j No Visible /Fine yer D i4 to 1"4 D> 1" j. %4
Description: I
Setbacks N/A 9
Floor.___ Debris:[] No Visible/Fine Layer El 34 to 1" 0> 1"
Floor.____ Debris: j] No Visible/Fine Layer 034 to 1" >10
Floor____ Debris: Q No Visible/Fine Layer 034 to? B > 1"
Floor. Debris:[] No Visible/Fine Layer []'h to 1" 0>10
Floor. Debris: D No Visible/Fine Layer E] 34 to 1" 0>10
Comments -,
" -' f~°'~'' , RJ COuZR )C n
Date: /2002 Inspection Team: Name: Agency:
Name: Agency:
I
NYC-WTC-000115846
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NYC-WTC_000115846Source: NYC Law Department, mirrored locally