WT( Vieiial Survav Form
Premise Address:
/ (qçntial pcam- g:i ~~_s5 c Building:
Block: Resi Commercial Name o
Lot: Mix Use E J Other ❑ r%1 IK
AKA's: i — r `'
# of S ones:
Building Owrj,erIManagetpeflt: Telephone Number: ( )
Name: L t,L/'-/ FAX: ( ) r7 r
Address:
On Site C n ct:
Name: k ,0 Dc 4 Telephone Number: ("..Xi) )-2C) - --
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 D Yes
Visual Inspection Results:
Facade:
Inspected Debris
North ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑ '/2 to 1" ❑ > 1"
South ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑'/2 to 1" ❑ > 1"
East ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑'h to 1" ❑ > 1"
West ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑ Y2 to 1" ❑ > 1"
Facade Description: j
L,
Roof
Debris: ❑ No Visible /Fine Layer ❑ % to 1" ❑ > 1"
Description:
Setbacks N/A ❑
Floor: Debris: ❑ No Visible/Fine Layer ❑'/2 to 1" ❑ > 1"
Floor: Debris: ❑ No Visible/Fine Layer ❑ '/2 to 1" ❑ > 1"
Floor: Debris: ❑ No Visible/Fine Layer ❑'/Z to 1" ❑ > 1"
Floor: Debris: ❑ No Visible/Fine Layer ❑'/z to 1" ❑ > 1"
Floor: Debris: ❑ No Visible/Fine Layer ❑'/z to 1" ❑ > 1"
Comments
/2002 Inspection Team: Name: Iw-t
` Name: .A&
NYC-WTC 000126996
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NYC-WTC_000126996Source: NYC Law Department, mirrored locally