WTC building inspection form, 111 Church Street, undated

NYC 9/11 Public Portal Document

WTC Visual Survey Form Premise Address:. Pt dres~oov~_ Block: Residential O Commercial Name of Building: Lot: Mix Use O Other # of Stories. S AKA's: /// .S-rem Building Owner/Management: Telephone Number: ( ) Name: FAX: Address: On Name: ! P11 Telephone Number: P11 Interior Survey Performed f Yes ❑ No Exterior Survey Performed Yes ❑ No General Clean Up ® Yes J I No Locations: ACM Clean Up ❑ Yes ❑ No Locations: Air Monitoring ❑ Yes ❑ No Locations: Copies of All Reports and Data Requested Yes Visual Inspection Results: Facade: Inspected Debris North ❑ N/A 13%s ❑ No ❑ No Visible/Fine Layer (4/2 to 1" ❑ > 1" South ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑ Y2 to 1" O>1" East ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑ % to 1" ❑ > 1" West ❑ N/A (AYes ❑ No ❑ No Visible/Fine Layer [ '/ to 1" ❑ > 1" Facade Description:

Roof

Debris: No Visible /Fine Layer ❑ Ya to 1" •, = ❑ > 1" ./ Description:

Setbacks N/A1E Floor. Debris: ❑ No Visible/Fine Layer ❑ % to I" O>1" Floor. Debris: O No Visible/Fine Layer ❑ % to I" ❑>1" Floor: Debris: O No Visible/Fine Layer O % to 1" O> 1" Floor: Debris: O No Visible/Fine Layer ❑ % to 1" O>1" Floor: Debris: ❑ No Visible/Fine Layer ❑ Y2 to 1" ❑>1" Comments ' /~ _ ~ ~ C'J'A

Date: I //2002 Inspection Team: Name: = Agency: " ~} Name: Agency: tP

NYC-WTC 000126509