Asbestos inspection data form for residential building facade and roof

NYC 9/11 Public Portal Document

WTC Visual

Survey Form I o©

Premise Ad ess: e

Block: esidential Commercial Name of Building: Lot: Mix Use Other - — # of S ones: AKA's: Building Owner/Management Telephone Number ( ) Name: FAX: Address: On Site Contact: Name: Telephone Number. (' Building Owner Management Activiti Interior Survey Performed ❑ Ye No Exterior Survey Perforped ❑ Yes General Clean Up s ❑ No Locations: ACM Clean Up 1J Ye o Locations: Air Monitoring ❑ Ye 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" 9>1" South ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer 9'/2 to 1" ❑ > 1" East ❑ N/A ' es ❑ No ❑ No Visible/Fine Layer / to 1" ❑ > 1" West ❑ N/A ❑ No ❑ No Visible/Fine Layer to 1" ❑ > 1" Facade Description:

Roof

Debris: ❑ No Visible /Fine Layer Description: ❑'/ to 1" J>lr

Setbacks N/A ❑ Floor: Debris: ❑ No Visible/Fine Layer 9'/2 to 1" ❑ > 1" Floor: Debris: ❑ No Visible/Fine Layer ❑'/2 to 1" ❑ > 1" Floor: Debris: ❑ No Visible/Fine Layer ❑ % to 1" ❑ > 1" Floor: Debris: ❑ No Visible/Fine Layer 91,4 to 1" ❑ > 1" Floor: Debris: ❑ No Visible/Fine Layer ❑ % to 1" ❑ > 1"

Date: ?/ , /2002 Inspection by: Name: Agency: Name: Agency:

NYC-WTC 000118097