Block: Residential 0 Commercia ame of Building:
Lot Mix Use 0 Other
# of Stories: 2 _ AKA's:
Building Owner/Management Telephone Number ( )
Name: FAX:
Address:
On Site Contact
Name: ' * .. Telephone Number.
Building Owner Management Activities
Interior Survey Performed ❑ Yes Q No
Exterior Survey Performed j] Yes D No
General Clean Up 0 Yes No Locations:
ACM Clean Up Yes No Locations:
Air Monitoring Yes 0 No Locations:
Copies of All Reports and Data Requested p Yes
Visual Inspection Results:
Facade:
Inspected Debris
North [] N/A 0 Yes ❑ No ❑ No Visible/Fine Layer % to 1" 0>1"
South ❑ N/A ❑ Yes ❑ No ❑ No Vsible/Fine Layer H%tol- 0>1"
❑ N/A ❑ Yes ❑ No 0>1"
East
West 9N/A
Facade Description:
j] Yes 0 No
A p L (~ n
9No Visible/Fine Layer ❑ h to 1"
No Visible/Fine Layer 934 to 1"
D
[]
❑ > 1"
M
Roof
Debris: o Visible /Fine Layer [] % to 1" Lj> 1"
Description:
Setbacks N/A 0
Floor. Debris: ❑ No Visible/Fine Layer r]'/ to 1"
Floor. Debris: 0 No Visible/Fine Layer ❑ % to 1"
Floor. Debris: ❑ No Visible/Fine Layer ❑ % to 1"
Floor.
Floor
Debris: No Visible/Fine Layer
No Visible/Fine Layer 0 Ys to 1"
h to 1"
Comments
Department of Environmental Protection inspection form for WTC-area building documenting facade condition, asbestos, and other environmental hazard assessments.