NYC 9/11 Public Portal Document
i
WTC Visual Survey Form
Premise Address:
2
I Residentia mmercial Name of Building:
Block:
Lot: I Mix Use Other
# of Stories: AKA's:
Building e/Managelnent: Telephone Number (?, t z) y - gk
Name: p e,~ QS~~ \ _ FAX:
Address:
On Site Contact:
Name: Telephone Number.
Building Owner Mans ement *clivlties
Interior Survey Performed Yes No
Exterior Survey Perfo ma es No
General Clear, Up9es I 1No Locations:_______________________________________
ACM Clean Up DYe No Locations:
Air Monitoring Res ❑ No Locations:
CO1L of All Reports and Data Reguest9 Yes
Visual Inscection Results:
Facade:
Inspected Dqbris
f
North ❑ N/A es j] No o Visible/Fine Layer ❑ Y2 to 1" >1"
South 0 N/A es ❑ No s -No Visible/Fine Layer % to 1" ] > 1"
East ❑ N/A s ❑ No NoVisible/Fine Layer HAto1" [] > 1"
West ❑ N/A f les
y1 [] No o Visible/Fine Layer ❑ %a to 1" 0>1"
Facade Description:
Roof
Debris: r'No Visible /Fine Layer ❑%to 1" 0>1"
Description: g________
Setbacks tJl~]
Floor. m Debris: No Visible/Fine Layer Y: to 1" ❑>1"
Floor. Debris: 0 No Visible/Fine Layer h to 1" 0>1"
Floor. Debris: ❑ No Visible/Fine Layer % to 1"
Floor. Debris: No Visible/Fine Layer ❑ h to 1" j]> 1"
Floor. Debris: J No Visible/Fine Layer ❑ 4 to 1"
Comments
,,:t:A ,
Date: Inspection Team: Name: t /" Agency: (UL- U
Name: Agency:
NYC-WTC-000117999
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