S ' PH0= TAD N D YES
R NA r ~~ r/~ BLDG TYPE 64$15 OF INSPECT. ' V
1
SAMPLE Na
:ONTRACTORS NAME t g~L C A; 2@t-
SAMPLE NO.
4 DRESS
CITY SAMPLE
c,0 8 "-% Q
_~ SAMPLE Na
,1 3 PMON
STATE l ► D
ZIP
LABOFiATQRY NAME Y Prs,~ f n
Ir~~ P
OWNE NAME .A-- r
An !ES.Sy CITY
A RES
CITY N .
STATE ZIP PHONE
STATE ZIP `1~O' O L^L~-OO
V TIME OF INSPECTION FROM: (yJ}1 TO: f S~ artUpf~n
CONTACT PERSON: o X7 v
INSPECTION DISCLOSED:
A
I RESULT CODE
[NOV. INFRACTIONS
NOV a
4 • QUEENS s .RICHMOND
BORO I . MANHATTAN 2 . $RONx 3 - BROOKLYN
BLDG TYPE A > 6 Stories B <6 Stories C Sinple Family
D School £ Hospital • F Public Owned Property
RESULT CODES I - Violation Issued 2 • No Violations Issued 3 - No Access
GCE" X4+9
4 - Project not Started (No NOV) 5 . Pmlgct COmplr!led (NO NOVI
FILE
NYC-WTC 000123364
OCR can misread numbers and units. Confirm readings against the page image before using them.
NYC-WTC_000123364Source: NYC Law Department, mirrored locally
Blank or template asbestos inspection report form with fields for building premises, contractor information, sample collection, and laboratory analysis.