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NYC 9/11 Public Portal Document

WTC Visual Survey Form Premise Address: f} vGnty Block: Residential Commercial Name of Building: Lot: Mix UseD Other # of Stories: AKA's: Building Owner/Management IRy ma-ic jrzcf. Telephone Number. (Z.(L.) T-3 ,t _7771 Name: FAX: C 1as Address: On Site Contact: Name: " ' 4 e-w Telephone Number. 72-) 4— 434( . Building Owner Management Activities Interior Survey Performed ❑ Yes ❑ No Exterior Survey Performed ❑ Yes ❑ No General Clean Up 0 Yes 0 No Locations: ACM Clean Up ❑ Yes 0 No Locations: Air Monitoring ❑ Yes [] No Locations: Copies of All Reports and Data Requested Yes

Visual Inscection Results: Facade: Inspected Debris North ❑ N/A 'Yes ❑ No No Visible/iine La r []%to 1" 0>1" South ❑ N/A E Yes ❑ No No Visible 0 1/%to 1" 0>1" East ❑ N/A Yes ❑ No No Visible r ❑ % to 1" 0>1" West ❑ N/A EJYesDNo No Visible ❑%to1" []>1" Facade Description:

Roof Debris: ❑ No Visible /Fine Layer ED % to 1" ❑ > 1" Description: 2e' Gyvr as yz' 2 C CaA L& W rc. .

Setbacks N/A ❑ Floor Debris: ❑ No Visible/Fine Layer 0 % to 1" 0>1" Floor. Debris: 0 No Visible/Fine Layer ❑ h to 1" > 1" Floor. Debris: ❑ No Visible/Fine Layer ❑ 34 to 1" > 1" Floor. Debris: ❑ No Visible/Fine Layer 034 to 1" ❑ > 1" Floor. Debris: ❑ No Visible/Fine Layer 034 to 1" 0>1" Comments

Date: o r i 10 nod Inspection Team: Name: R - R A r''7 t7W N f3 Agency: P C 12)6P. Name: Jt t e- s cob y, Agency: Us EPA ENTERS NYC-WTC-000117418