WTC facade inspection form for residential building, June 2002

NYC 9/11 Public Portal Document

WTC Visual Survey Form BN\ t* 1001264 Premise Address: Fu 1 19 -For S+r-ee+ Block:g Residential 0 Commercial Name of Building: Lot: Mix Use iJ 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 p Yes

visual inspection Results: Facade: Inspected Debris North ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer % to 1" ❑ > 1" South ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer J Va to 1" ❑ > 1" East ❑ N/A Yes ❑ No ❑ No Visible/Fine Layer Y2 to 1" 0>1" West ❑ N/A ❑ Yes [] No ❑ No Visible/Fine Layer J 4 to 1" ❑ > 1" Facade Description:

Roof

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

Setbacks N/A ❑ Floor: Debris: ❑ No Visible/Fine Layer ❑ % to 1" ❑ > 1" Floor: Debris: ❑ No Visible/Fine Layer ❑ %: to 1" ❑ > 1" Floor: Debris: ❑ No Visible/Fine Layer ❑ Va to 1" ❑ > 1" Floor Debris: ❑ No Visible/Fine Layer ❑'4 to 1" ❑ > 1" Floor. Debris: ❑ No Visible/Fine Layer ❑ Va to 1" ❑ > 1" Comments

Date: a / 0 6 /2002 Inspection by: Name: AP Agency: D EP Name: Agency:

NYC-WTC-000119627