NYC 9/11 Public Portal Document
WTC Visual Survey Form
Premise Address:
Block: Residential 0 Commercial Name of Building:
Lot: Mix UseD Other
# of Stories: AKA's:
Building Owner/Management: Telephone Number. ( )
Name: FAX:
Address: /C-o ~s
On Site Contact: 7ke.. q ,,,f1J ,' p~
Name: Telephone Number
Building Owner Management Activities
Interior Survey Performed Yes Q No
Exterior Survey Performed es No
General Clean Up J Yes D No Locations:
ACM Clean Up Yes ❑ No Locations:
Air Monitoring Yes ❑ No Locations:
Copies of All Reports and Data Requested J Yes
Visual Inspection Results:
Facade:
Inspected Debris
North ❑ N/A EYes ❑ No !~No Visible/Fine Layer ❑'/to1" 0>1"
South ❑ N/A EYes ❑ No No Visible/Fine Layer 0%to1" 0>1"
East ❑ NIA Yes 0 No No Visible/Fine Layer 0%to1" 0>1"
West ❑ N/A 'Yes ❑ No No Visible/Fine Layer ❑%to 1" 0>1"
Facade Description:
Roof
Debris: No Visible /Fine Layer [] % to 1" 0> 1"
Description:
Rc2 ter t # , - - c.
Setbacks N/A D
Floor Debris: 0 No Visible/Fine Layer 034 to 1" 0>1"
Floor. Debris: ❑ No Visible/Fine Layer ❑ h to 1" > 1"
Floor. Debris: ❑ No Visible/Fine Layer ❑ % to 1" > 1"
Floor. Debris: 0 No Visible/Fine Layer ❑ 4 to 1" > 1"
Floor____ Debris: 0 No Visible/Fine Layer ❑ % to 1" 9>1"
Comments
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Date: ` / 12002 Inspection Team: Name: 1Z, J IM~9 ✓ Agency: ~`1c
Name: Agency:
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NYC-WTC 000122533
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