WTC building facade inspection form

NYC 9/11 Public Portal Document WTcMiu —if Survey Form Premise Address:

Block: ' 7Residential Commercial Name of Building: Lot Mix UseD 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 No Exterior Survey Performed Yes No General Clean Up ACM Clean Up Air Monitoring 0 Yes No Locations: Yes No Locations: D Yes 9 No Locations: Copies of All Reports and Data Requested Yes Visual Inspection Results: Facade: Inspected Debris North N/A Yes No No Visible/Fine Layer % to 1" >1' South [i N/A YesE] No No Visible/Fine Layer 34 to? >1' East N/A Yes No No Visible/Fine Layer % to 1' >1' West J N/A Yes No ~ No Vsible/Fine-Layer h to? 9>1' Facade Des ption:

Roof Debris: r] No Visible /Fine Layer [] % to 1' 9>1' Description: O __

Setbacks N/A~ Floor. Debris: No Visible/Fine Layer ❑ % to 1" >1' Floor.____ Debris: No Visible/Fine % to 1' >1' Floor____ Debris: No Visible/Fine Layer % to 1' >1' Floor„__ Debris: No Visible/Fine Layer 34 to 1" >1' Floor Debris: Q No Visible/Fine Layer LayerH%to 1' >1' Comments

Date: 12.712002 Inspection Team: Name: f. ',ha R_ C tkAgercy OEF Name: Agency: ENTERED

NYC-WTC 000117170