Asbestos inspection form, 40 [name]

NYC 9/11 Public Portal Document

WTC Visual Survey Form (00(2 Premise Address:

Block: z q esidentia1FJ Commercial t..ro Name of Building: J Lot: I Mix Use Oth r ❑ # 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 El No Locations: Air Monitoring ❑ Yes ❑ No Locations: Copies of All Reports and Data Requested Yes

Visual Inspection Results: Facade: Inspected bris North ❑ N/A ❑ Yes ❑ No Eli No Visible/Fine Layer ❑'/ to 1" 0>1" South ❑ N/A ❑ Yes ❑ No Eli No Visible/Fine Layer ❑ Y to 1" 0>1" East ❑ N/A ❑ Yes ❑ No EJJ No Visible/Fine Layer El% to 1" 0>1" West ❑ N/A ❑ Yes ❑ No No Visible/Fine Layer ❑YY2to1" 0>1" Facade Description:

Roof

❑ No Visible /Fine Layer Debris: Description: X /2 to 1" 0>1"

Setbacks N/A ❑ Floor: Debris: ❑ No Visible/Fine Layer ❑'!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 ❑ Y to 1" ❑ > 1" Floor: Debris: ❑ No Visible/Fine Layer ❑ % to 1" ❑ > 1"

Comments

Date: 4_J_%..42002 Inspection by: Name: Agency: ~~ Name: Agency:

NYC-WTC-000119428