VENTILATION SYSTEM EVALUATION FORM
• Part 1.0 General Information
ate of Evaluation; j„ o OZ. Buii ing contact name and phone: Tjo okyg l- i
Evaluation Ten (list name and affiliation):
L ~gZ.E}1SoV (nvironmental Professiona )
( ur(iP(HVAC1Ecctrical Professional)
(Sheet Metal ofessiona )
Building A ess: Type of Facility (check all that apply):
,f'' ao.rtr} Rcsidentia3
U u d-use
Cher (describe)
umber of rest ential units: pp Number of floors:
IJVA System Types (check ail that apply) '
Unit ventilator (single residence unit) Walt/win ow AC unit (single residence unit)
tJFan coil unit (single residcncc unit) f Central ventilation system
Heat pump unit smg3e res dence unit) Passive shaft/duct
fj Other (describe)
Location of outside air intake:
Outside air intake accessible for inspection Y N (explain)
Part 2.0 Checklists
2.1 Ventilators, wall air conditioning units and window air conditioning units In common spaces
Ventilation System I entification: i2 -t
VAG
Location:
Access adequate for inspection of components:
Dust/Dirt 1 e ris Suspect WT - elated Dust
System Component
Substrate Material
(sheet metal wrapped) Light Heavy
Present? Estimate % of total dust
System Components (sheet metal lined) None (.i/16 inch (z 1/16 inch (Y/N) loading
(fiberglass) depth) depth
(flexible connector)
(double wailed)
Outside air intake ouvcrs. grates
and/or screens u M t v1 ✓
Outside air duct
Outside air damper(s)
Return air guile
Return air plenum
filter rac
Filter media Lo
Coils (evaporator) p wee .
Blower assembly ,y a
Condensate drain pan
In- ire electrical resistance strip
heaters (in supply ducts
connected to unit ventilators)
iredampers
urn ng vanes
Supp y a r plenum or supply uet
Supply air plenum or supply duct
liner
Supply air diffuser
2.1 Ventilators, wait air conditioning units and wi
NYC-WTC 000117574
OCR can misread numbers and units. Confirm readings against the page image before using them.
NYC-WTC_000117574Source: NYC Law Department, mirrored locally