WTC Visual Survey Form 10000
Premise Address:
,
Block: $ % Residential El Commercial ❑ Name of Building:
Lot: Mix Use ❑ Other ❑
# of Stories: AKA's:
Building Owner/Management: Telephone Number: ( )
Name: FAX: ( )
Address:
On Site Contact:
Name: Telephone Number: ( )
Building Owner Management Activities
Interior Survey Performed ❑ Yes ❑ No
Exterior Survey Performed ❑ Yes ❑ No
General Clean Up ❑ Yes ❑ No Locations:
ACM Clean Up ❑ Yes ❑ No Locations:
Air Monitoring ❑ Yes ❑ No Locations:
Copies of All Reports and Data Requested ❑ Yes
Visual Inspection Results:
Facade:
Inspected Debris
North ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑'/2 to 1" ❑ > 1"
South ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑ Y2 to 1" ❑ > 1"
East ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑ Y2 to 1" ❑ > 1"
West ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑'/ to 1" ❑ > 1"
Fac e Description:
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Roof
Debris: ❑ No Visible /Fine Layer ❑'/2 to 1" ❑ > 1"
Description:
Setbacks N/A ❑
Floor: Debris: ❑ No Visible/Fine Layer ❑ '/2 to 1" ❑ > 1"
Floor: Debris: ❑ No Visible/Fine Layer ❑'/z to 1" ❑ > 1"
Floor: Debris: ❑ No Visible/Fine Layer ❑ Y2 to 1" ❑ > 1"
Floor: Debris: ❑ No Visible/Fine Layer ❑ 1/ 2 to 1" E1> 1"
Floor: Debris: ❑ No Visible/Fine Layer ❑'/ to 1" ❑ > 1"
Comments -
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Date: L' //2002 Inspection by: Name: %4t4 ' I H&Qoj2,Z9 -tcAgency:
Name: Agency:
NYC-WTC-000119328
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NYC-WTC_000119328Source: NYC Law Department, mirrored locally
Standardized inspection form documenting building characteristics, asbestos materials assessment, and visual inspection results for facade debris on all four sides.