NYC 9/11 Public Portal Document
WTC Visual. Survey Form
Premise Address: , ( "{+ ~~ f
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Block: Residential Commercial Name of Building:
Lot: Mix Use 0 Other
* of Stories: r- AKA's:
Building Owner/Management: Telephone Number ( )
Name: FAX: )
Address:
On Site Contact:
Name: - Telephone Number:
Building Owner Management Activities
Interior Survey Performed ❑ Yes 0 No
Exterior Survey Performed 0 Yes 0 No
General Clean Up ❑ Yes 0 No Locations:
ACM Clean Up ❑ Yes 0 No Locations:
Air Monitoring ❑ Yes 0 No Locations:
Copies of All Reports and Data Requested D Yes
Visual Inspection Results:
Facade:
Inspected Debris
] Yes [A No ❑ No Visible/Fine Layer ❑'/ to 1" 0>1"
North ❑ NIA
N/A ® Yes ® No [ No Visible/Fine Layer [ '/a to 1" ❑ > 1"
South D
East D N/A 0 Yes 0 No ❑ No Visible/Fine Layer [D"/a to 1" E1> 1"
❑ N/A ❑ Yes[{ No ❑ No Visible/Fine Layer ❑'Vi to 1" ❑ > 1"
West
Facade Description: r
r tit , c c~> 11v1 5 %~L 1 1
l rat f..4
Roof
Debris: ❑ No Visible /Fine Layer , ©% to 1" 0>1"
Description: ( S -? ! L' C 1) ' -4 I -'
Setbacks N/A 0
Floor. Debris: 0 No Visible/Fine Layer ❑'/z to 1" ❑ > 1"
Floor. Debris: 0 No Visible/Fine Layer 0'/x to 1" 0> 1"
Floor. Debris: 0 No Visible/Fine Layer 0'/z to 1" ❑ > 1"
Floor. Debris: 0 No Visible/Fine Layer 0 Va to 1" 0> 1"
Floor Debris: 0 No Visible/Fine Layer ❑ Va to 1" 0> 1"
Comments
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Agency:
Name:
A11139
NYC-WTC 000127491
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