WTC Visual Survey Form
Premise Address: - -'~
Residential 0 ComrnerciaQ
k'Jof Building:
Block: Name
Lot: Mix Use fl 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 n No
General Clean Up Q Yes ❑ No Locations:
ACM Clean Up ❑ Yes Q No Locations:
Air Monitoring 9 Yes Q No Locations:
Copies of All Reports and Data Requested fl Yes
Visual Inspection Results:
Facade:
Inspected Debris
North 0 N/A 0 Yes ❑ No O No Visible/Fine Layer ❑%to1" 9>1
South ❑N/A es0No o Visible/Fine Layer %tot" D>1'
East N/A J Yes No No Visible/Fine Layer % to 1' 0 > 1w
West O N/A Yes 8 No No Visible/Fine Layer 36tol D>1"
Facade Description:
Roof
Debris: j] o Visible /Fine Laye to 1" 9>r
Description: cam- t. w. ( a... _
Yt0 - ZC S
Setbacks N/A ❑
Floor___ Debris:9 No Visible/Fine Layer 0% to 1' 9>10
Floor. Debris:9 No Visible/Fine Layer 0 Va to 1' 9 ) 10
Floor___ Debris: No Visible/Fine Layer 0Va101 0>1'
Floor____ Debris: ❑ No Visible/Fine Layer 0% to 1' > 1'
Floor.___ Debris: ❑ No Visible/Fine Layer 9 % to 1' ] >1'
Comments
( '
Date: / 12002 Inspection Team: Name: Agency:
Name: Agency:
ENTER E
NYC-WTC 000122256
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NYC-WTC_000122256Source: NYC Law Department, mirrored locally