WTC Visual Survey Form Cover Page

NYC 9/11 Public Portal Document

C'Visuai SurveyForm Premise Address: - Buck: cm Residential 0 Commercial Name of Building: Lot Mix Use 0 Other # of Stories: 2.. AKA's: Building Owner/Management Telephone Number. ( ) Name: k c FAX: Address: On Site Contact: Name:' ' Telephone Number. Building Owner Management Activities • Interior Survey Performed Yes D No Exterior Survey Performed U Yes ❑ No General Clean Up ❑ Yes No Locations: ACM Clean Up 0 Yes No Locations: Air Monitoring j] YesD No Locations: Copies of All Reports and Data Requested J Yes

Visual inspection Results: Facade: Inspected Debris North N/A Yes No No Visible/Fine Layer 014to1' 9V South B N/A DYes No No Visible/Fine Layer '/to1' >1' East ❑ N/A DYesDNo No Visible/Fine Layer l4to1' >1' West N/A JYesDNo No Visible/Fine Layer 0 2 to 1 '* 14t01 > 1 '

Facade Des ption:

Roof Debris: 0No Visible /Fine Layer I] 3.4 to V ❑ >V Description: NO _GEC QG

Setbacks N/A 0 Floor. Debris:DNo Visible/Fine Layer 34 to 1' > 1' Floor Debris: No Visible/Fine Layer 36 to 1' > 1' Floor Debris: No Visible/Fine Layer % to V > 1' Floor___ Debris: No Visible/Fine Layer 3.4 to 1' > 1' Floor__ Debris: D No VisIble/Fine Layer % to V > 1' Comments

Date: „4- /J 002 inspection Team: Name: j). XaI f eWlkApency:DEP Name: Agency:

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