WTC facade inspection form, [name] Avenue

NYC 9/11 Public Portal Document

0 0f 4k a A i WTc Visual Survey Form Premise Add ess: 11

Block: Residential 0 Commercial Name of Building: Lot: Mix Use 0 Other # of Stories: AKA'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 Q Yes Q 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 J Yes Visual Inspection Results: Facade: Inspected Debris North ❑ N/A Q Yes ❑ No ❑ No Visible/Fine Layer Q Ya to l" 0>1' South ❑ N/A ❑ Yes ❑ No [] No Visible/Fine Layer [] Ya to l" 0>1" East ❑ N/A ❑ Yes ❑ No Q No Visible/Fine Layer ❑ % to 1" []>l" West Q N/A Q Yes ❑ No Q No Visible/Fine Layer 034t01" 0>1" Facade Description:

Roof

Debris: ❑ No Visible /Fine Layer []'% to 1" [] > 1" Description:

Setbacks N/A Q Floor: Debris: ❑ No Visible/Fine Layer ❑ Va to 1" ❑ > 1" Floor Debris: Q No Visible/Fine Layer 0 % to 1" ❑ > 1" Floor: Debris: Q No Visible/Fine Layer 0 Yz to 1" ❑ > 1" Floor. Debris: Q No Visible/Fine Layer ❑ Y: to 1" ❑ > 1" Floor. Debris: [] No Visible/Fine Layer 0 Y: to 1" 0> 1" Comments 4

Date: ~/ 21 /2002 Inspection Team: Name: Agency: Name: Agency: V NYC-WTC 000116047