WTC facade inspection form for residential building, June 2002

NYC 9/11 Public Portal Document

WTC Visual Survey Form IO0I2(ôq Premise Address: TR Block: Residential Commercial Name of Building: Lot: Mix Use Other # of Sto es: AKA's: Building Owner/Management: elephone Number: ( Name: FAX: ) Address: On Site Contact: Name: Telephone Number: Building Owner Management Activities Interior Survey Performed ❑ Yes ❑ No Exterior Survey Performed [J 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 es

Visual Inspection Results: Facade: Inspected Debris North ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer 0'/ to 1" 0>1" South ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑'/ato1" 0>1" East ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer El'f to 1" 0>1" West ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑'/a 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 ❑'/a to 1" ❑ > 1" Floor: Debris: ❑ No Visible/Fine Layer ❑'/z to 1" ❑ > 1" Floor: Debris: ❑ No Visible/Fine Layer ❑ % to 1" ❑ > 1" Floor. Debris: ❑ No Visible/Fine Layer ❑'/a to 1" ❑ > 1" Floor. Debris: ❑ No Visible/Fine Layer ❑ % to 1" ❑ > 1"

Comments

Date: Inspection by: Name: Agency: Name: Agency:

NYC-WTC-000119624