WTC Visual Survey Form Bm*100IZZA
Premise Address: r~0 a -Bro a d w
Block: 71 Residential U Commercial J Name of Building:
Lot: l9 Mix Use 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 ❑ No
General Clean Up ❑ Yes ❑ No Locations:
ACM Clean Up ❑ Yes ❑ No Locations:
Air Monitoring ❑ Yes [j No Locations:
Copies of All Reports and Data Requested D Yes
visual inspection Results:
Facade:
Inspected Debris
North ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer % to l" [J>1"
South ❑ N/A ❑ Yes ❑ No ❑ No Vsible/Fine Layer % to 1" E]> 1"
East ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer % to 1" 0>1"
West ❑ N/A ❑ Yes ❑ No ❑ No Vsible/Fine Layer % to l" [J>1"
Facade Descriptisn4~~
Ui~
Roof
Debris: ❑ No Visible /Fine Layer ❑ % to 1" ❑ > 1"
Description:
Setbacks N/A ❑
Floor. Debris: ❑ No Visible/Fine Layer ❑ 34 to 1" ❑ > 1"
Floor. Debris: ❑ No Visible/Fine Layer ❑ %z to 1" ❑ > 1"
Floor. Debris: ❑ No Visible/Fine Layer ❑'h to 1" ❑ > 1"
Floor. Debris: ❑ No Visible/Fine Layer ❑'/ to 1" ❑ > 1"
Floor Debris: ❑ No Visible/Fine Layer ❑'/2 to 1" ❑ > 1"
Comments
Date: / 1512002 Inspection by: Name: AP Agency: D( P
Name: Agency:
NYC-WTC 000123247
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NYC-WTC_000123247Source: NYC Law Department, mirrored locally