WTC facade inspection form, 200 Church Street

NYC 9/11 Public Portal Document ,f WTC Visual Survey Form Premise Address: çi ( 1L Block: Residential Name of Building: Lot MixUseD Other * of Stories: AKA's: Building Owns anagem•nt: 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 tocstions: Air Monitoring Yes No locations: Copies of All Reports and Data Re uested Yes Visual Inspection Results: Facaas: Inspected Debris North N/A Yes No No Visible/Fine 34 to1' > 1' South N/A Yes No No Visible/Fine Layer 34 to 1 >1' East N/A Yes No No Visible/Fine Layer % to 1' > 1' West NIA Yes No No Vaible/Fine LayerHYstOle Layer N3010 Facade Description:

Roof f Debris: atibie 1Fine layer ] X to 1• ] >! Desc riotio •

Setbacks WAD Floor._,_,_ . Debris: No Visible/Fine Le 34 to? >1' Floor.,_ Debris: No VisiblelFine Layer J 34 to 1' > 1' Floor.___ Debris: No Visible/Fine Layer % to l' > 1' Floor:,___ Debris: No Visible/Fine Layer % to 1' > 1' Flow:__ Debris: No Visible/Fine Layer 34 to1' > 1' Comm.Ms

•1 l01 inspection Team: Name: Name: ENTER

NYC-WTC 000126483