NYC 9/11 Public Portal Document
!0-77 22,,,E
WTC Visual Survey Form
Premisq Address:
3yf ct,,F 5,-rR 1- pove Mc W'/4,Ds ON Sr-
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Block: 5 Residential U Commercial Q Name of Building:
Lot: g Mix Use J Other
# of Stores: 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 ❑ No Locations:
Copies of All Reports and Data Requested U Yes
Visual Inspection Results:
Facade:
Inspected Debris
North ❑ N/A Yes ❑ No E"No Visible/Fi ef---❑ % to 1" 0>1"
South SN/A D Yes ❑ No No Visible/ yer ❑'/2 to 1" 0>1"
East [0 N/A ❑ Yes ❑ No 0 No Visible/Elie-Layer ❑ 1/2 to 1" ❑ > 1"
West ❑ N/A 0 Yes ❑ No ❑ No Visible/Fine Layer ❑ 1/2 to 1" ❑ > 1"
Facade Description:
Roof
Debris: 'No Visible /.Fine.Layer- ❑ % to 1" ❑ > 1"
Description: 1 c4 tv ful 2 ?~ c Z.a
Setbacks N/A P9
Floor: Debris: ❑ No Visible/Fine Layer ❑ Y2 to 1" ❑ > 1"
Floor: Debris: ❑ No Visible/Fine Layer 0'/2 to 1" ❑ > 1"
Floor: Debris: ❑ No Visible/Fine Layer ❑'/2 to 1" ❑ > 1"
Floor: Debris: ❑ No Visible/Fine Layer 0 '/2 to 1" E1> 1"
Floor: Debris: ❑ No Visible/Fine Layer ❑ Y2 to 1" ❑ > 1"
Comments
Date: -1'T2002 Inspection Team: Name: (h~4.~,. 0 r Agency: !~ G c
Name: Agency:
NYC-WTC 000126392
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