WTC Visual Survey Form
Premise Address:
9Z CfjombeY Street
Block: Residential Commercial J Name of Building:
Lot: Mix Use Other
# of Stories: AKA's:
Building Owner/Management: F-iamtx=rder 4rz0n kavzrTelephone Number: ( )
Name: FAX: ( )
Address:
On Site Contact: 7e
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 K8SUIrS:
Facade:
Inspected Debris
North ❑ N/A 'Yes ❑ No No Visible/Fine Layer ❑'/2 to 1" 0>1"
South ❑ N/A ❑ Yes ❑ No tJ No Visible/Fine Layer ❑ % to 1" ❑ > 1"
East ❑ NIA ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑ % to 1" ❑ > 1"
West ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer. ❑'/ to 1" ❑ > 1"
Facade Description:
Roof
Debris: ®Nie-Vici14e /Fine Layer j'/2 to 1" 0>1"
Description: fir+ Lr //%ke )14t4 d y ewrj
Setbacks N/A ice+,
Floor: Debris: ❑ No Visible/Fine Layer 0'/2 to 1" ❑ > 1"
Floor: Debris: ❑ No Visible/Fine Layer ❑'/ to 1" ❑> 1"
Floor: Debris: ❑ No Visible/Fine Layer ❑'/2 to 1" ❑ > 1"
Floor: Debris: ❑ No Visible/Fine Layer 0'/2 to 1" ❑ > 1"
Floor: Debris: ❑ No Visible/Fine Layer ❑ % to 1" ❑ > 1"
Comments
4r»~czC% A.•- cwnes. A(o &ce(- & R-
le
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Date: Oil 24-/2OO2 Inspection Team: Name: /e Agency: USED,
Name: R • R4P7/k cif/A'v Agency: Myc .a EP
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NYC-WTC 000122117
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NYC-WTC_000122117Source: NYC Law Department, mirrored locally