Building inspection form, 123 Barclay Street

NYC 9/11 Public Portal Document 12'/2 a WTC Visual Survey Form (7) dv

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j Premise Address: • (0/ g a- t' Block: ResidentialD Corn ercial Name of Building: Lot: Mix Use J Other J J # 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 j J Yes

Visual inspection Results: Facade: Inspected Debris North ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑ Y to 1" 0>1" South ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑ % to 1" 0>1" East ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer D Y2 to 1" 0>1" West ❑ N/A ❑ Yes 0 No ❑ No Visible/Fine Layer 036 to 1" ❑ > 1" Facade Description: •. r ' -) -AaQL. t S

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Roof N Debris: [lo Visible /Fine yer- ❑ 34 to 1" 4' ❑ > 1" 1 • Description:

Setbacks N/A ❑ Floor. Debris: ❑ No Visible/Fine Layer 036 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" 0> 1" Floor Debris: ❑ No Visible/Fine Layer ❑ % to 1" ❑ > 1"

Comments

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NYC-WTC-000119859