DEP letter requesting environmental data for 21 South End Ave,

NYC 9/11 Public Portal Document

C VYTC Visual Survey Form - mise Address: ,,,~

Block: I Residents Commercial J J Name of Building: Lot: '7 5O7 Mix Use Other # of Stores: AKA's: s Building Own anagempt: Qe hone Nu r. (2~-~_) I --15'S-'o AX: ( 1_I Address: On Site Contact:— Name: * * ` '0 -- e-- Telephone Number: Building Owner Management Acti4iltles Interior Survey Performed [,Yes ❑ No Exterior Survey Performed 'es ❑ No General Clean Up D %'es ❑ No Locations: Sc,,, - ACM Clean Up ❑ Yes Flo Locations: Air Monitoring comes ❑ No Locations: Copies of All Reports and Data Requested Yes Visual Inspection Results: Facade: In ected Debris

t North ❑ N/A fJYesDNo o Visible/Fine Layer ❑Y2to1" 0>1" South ❑ N/A YesDNo o Visible/Fine Layer ❑%to 1" 0>1" East 0 N/A Yes ❑ No o Visible/Fine Layer ❑%to1" 0>1" West ❑ N/A aYes ❑ No o Visible/Fine Layer ❑Mato 1" 0>1" Facade Description:

Roof

Debris: 5No Visible /Fine Layer ❑ % to 1" ❑ > 1"

Setbacks Floor: Debris: 0 No Visible/Fine Layer ❑ % to 1" ❑ > 1" Floor Debris: ❑ No Visible/Fine Layer ❑ % to V ❑ > 1" Floor. Debris: ❑ No Visible/Fine Layer ❑ % to 1" ❑ > 1" Floor: Debris: ❑ No Visible/Fine Layer ❑ Va to 1" ❑ > 1" Floor: Debris: ❑ No Visible/Fine Layer ❑ % to 1" ❑ > 1" Comments

Date: Inspection Team: Name: Name: Agency:

NYC-WTC 000117322