Asbestos inspection form, 40 [name]

NYC 9/11 Public Portal Document

Premise Addre WTC Visual Survey Form QO/Z67 Block: Residential Commercial Name of Building: Lot: Mix Use ❑ Other - — # of Stories: AKA's: Building Owner/Management: elephone um c ( ) 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 j Yes Visual Inspection Results: Facade: Inspected Debris North ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑ V to 1" 0>1" South ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑ V to 1" ❑ > 1" East ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑ V to 1" 0>1" West ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑ V to 1" 0>1" Facade Description:

Roof

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

Setbacks N/A ❑ Floor: Debris: ❑ No Visible/Fine Layer ❑ Y2 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 ❑ Y2 to 1" ❑ > 1" Floor: Debris: ❑ No Visible/Fine Layer ❑ Y2 to 1" ❑ > 1"

Comments

Date: Inspection by: Name: __,~• Agency: Name: Agency:

NYC-WTC-000119429