Asbestos inspection form, 40 [name]

NYC 9/11 Public Portal Document

WTC Visual Survey Form Premise Address: 1 " Cu ti n C r~ 'C f Bloclçj ¶ Residential 0 Commercial Name of Building: Lot:% Mix Use ❑ Other ❑ # of Stories: AKA's: Building Owner/Management elephon 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 ris North ❑ N/A ❑ Yes ❑ No o Visible/Fine Layer ❑%to1" 0>1" South ❑ N/A ❑ Yes ❑ No o Visible/Fine Layer ❑ l2 to 1" 0>1" East ❑ N/A ❑ Yes ❑ No f o Visible/Fine Layer ❑%to 1" 0>1" West ❑ N/A ❑ Yes ❑ No o Visible/Fine Layer [:]'% to 1" 0>1" Facade Description:

Roof

Debris: Description: A No Visible /Fine Layer ❑ Y to 1" 0>1"

Setbacks N/A ❑ Floor: Debris: ❑ No Visible/Fine Layer 0'!2 to 1" ❑ > 1" Floor: Debris: ❑ No Visible/Fine Layer ❑ Y2 to 1" ❑ > 1" Floor: Debris: ❑ No Visible/Fine Layer ❑ % to 1" ❑ > 1" Floor. Debris: ❑ No Visible/Fine Layer ❑ % to 1" ❑ > 1" Floor: Debris: ❑ No Visible/Fine Layer ❑ % to 1" ❑ > 1"

Comments

Date: //2002 Inspection by: Name: Ali Agency: _t Name: Agency:

NYC-WTC-000119427