NYC 9/11 Public Portal Document
' WTC Visual Survey Form 1 o
PremiseAddress:
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Block: 1 Residential fl Commercial Name of Building:
Lot: I Mix Use 0 Other ❑
# of Stories: 7 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 Q No Locations:
Copies of All Reports and Data Requested U Yes
visual inspection Kesuits:
Facade:
Inspected Debris
North ❑ N/A [ Yes ❑ No No Visible/Fioe€eyer ❑ % to 1" ❑ > 1"
South ❑ N/A ®'Yes ❑ No No Visible/ ta.+ ryrer- ❑ % to 1" ❑ > 1"
East N/A ❑ Yes Q No ❑ No Visible/Fine Layer ❑ % to 1" ❑ > 1"
West N/A ❑ Yes Q No ❑ No Visible/Fine Layer ❑ % to 1" ❑ > 1"
Facade Description:
Debris: (0 No Visible /Fins ❑ %% to 1" ❑ > 1"
Description:
Setbacks N/A Ea
Floor: Debris: ❑ No Visible/Fine Layer ❑ % to 1" ❑ > 1"
Floor: Debris: ❑ No Visible/Fine Layer ❑ % to 1" ❑ > 1"
Floor: Debris: ❑ No Visible/Fine Layer ❑ % to 1" ❑ > 1"
Floor: Debris: ❑ No Visible/Fine Layer ❑ % to 1" ❑ > 1"
Floor: Debris: ❑ No Visible/Fine Layer ❑ % to 1" ❑ > 1"
Comments
I '14 Nei ✓ 11'D) P
Date: /I /2002 Inspection by: Name: tom'ct7rii ha. Agency: DAP.
Name: Agency:
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NYC-WTC 000126014
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