NYC 9/11 Public Portal Document
WTC Visual Survey Form
Premise Address: .,
Block: Residential Commercial Name of Building: ' 'f! i C " /
Lot: Mix Use ® Other
# of Stori s: AKA's:
Building Owner/Management:
2.
/ WcI
x7/A' / I9i-/73
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 Yes
visual inspection Kesuits:
Facade:
Inspected Debris
North Q N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑'/2 to 1" ❑ > 1"
South ❑ N/A ❑ Yes ❑ No ❑x" No Visible/Fine Layer ❑'/ to I" ❑ > 1"
East Q NIA ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑'/2 to 1" ❑ > 1"
West ❑ N/A ❑ Yes ❑ No [] No Visible/Fine Layer ❑'/2 to 1" ❑ > 1"
Facade Description:
Roof ✓
Debris: Q No Visible /Fine ayer ❑'h to 1" •1 '' ❑ > 1" 1
Description:
Setbacks N/A J
Floor: Debris: ❑ No Visible/Fine Layer ❑'/2 to 1" ❑ > 1"
Floor: Debris: ❑ No Visible/Fine Layer ❑'/2 to 1" ❑ > 1"
Floor: Debris: ❑ No Visible/Fine Layer El 1/2 to 1" ❑ > 1"
Floor: Debris: ❑ No Visible/Fine Layer ❑'A to 1" ❑ > 1"
Floor: Debris: [] No Visible/Fine Layer ❑'/2 to 1" ❑ > 1"
Comments ;
C~✓.0 l %,-T
H'
/'l'" -. .
Date: /_/ 7` >✓ /2002 Inspection Team: Name: /r Agency: (' .
Name: /L, /C d ,,a .i c;'t i ,ti., Agency: i
34
NYC-WTC 000122053
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