NYC 9/11 Public Portal Document
WTC Visual Survey Form 1001173
remise Address:
Cc.i P
Block: 15 Residential J Commercial E Name of Building:
Lot: Mix Use ❑ Other El
# 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 ❑ No Locations:
Copies of All Reports and Data Requested Yes
visual vnspecuvrn r%tMUIw.
Facade:
Inspected Debris
North N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑'/z to 1"
South N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑'/2 to 1"
East fl N/A ® Yes ❑ No ❑ No Visible/Fine Layer ❑ '/2 to 1"
West ❑ N/A Yes ❑ No No Visible/Fine Layer ❑ Y2 to 1"
Facade Description:
p~ ~ 5~iS
Roof ~ w,. ~ c.~~
Debris: No Visible /Fine Layer ❑ % to 1" ❑ > 1"
Description: p p La c sz wed. ~ 1~ - 11
Setbacks N/A
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 0'/2 to 1" ❑ > 1"
Floor: Debris: ❑ No Visible/Fine Layer ❑ 1/ 2 to 1" ❑ > 1"
Comments
Date: " "'O'2 Inspection Team: Name: mohaLn Agency:
Name: Agency:
2)2o /02_ ,
NYC-WTC 000126410
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