Asbestos disposal form, 2002

NYC 9/11 Public Portal Document

WTC Visual Survey Form Premise Address: _

Block: Residential ❑ Commercial j Name of Building: Lot: Mix Use [2] Other ❑ # of Stories: 5 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 Inspection Results: Facade: Inspected Debris ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑ Y2 to 1" O>1" North © Yes ❑ No [g No Visible/Fine Layer ❑' to 1" O>1" South 0 N/A ❑ No Visible/Fine Layer ❑'/ to 1" ❑ > 1" East ❑ N/A ❑ Yes ❑ No West ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑ % to 1" O>1" Facade Descnpt'ion.

Roof

Debris: ❑ No Visible /Fine Layer ❑ %2 to 1" ❑ > 1" Description:

Setbacks N/A ❑ Floor: Debris: ❑ No Visible/Fine Layer ❑% to 1" ❑ > 1" Floor: Debris: ❑ No Visible/Fine Layer O½ to 1" ❑ > 1" Floor: Debris: ❑ No Visible/Fine Layer O½ to 1" ❑ > 1" Floor: Debris: ❑ No Visible/Fine Layer O½ to 1" ❑ > 1" Floor: Debris: ❑ No Visible/Fine Layer ❑% to 1" ❑ > 1"

Comments

Date: ! /2002 Inspection Team: Name: ______________________Agency: Name: Ji k-r t K Agency:

NYC-WTC 000127301