WC Visual Survov Form
Premise Address:
FJt
Block:
Lot
Residentia!J2 Commercial
Mix Use OtherlJ
ci
Name of Building:
# of Stories: AKA's:
Building Owns, ana a nt Telephone Number ( )
Name: FAX
Address:
On Site Contact
Namd: ' ' 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 9 No Locations:
Copies of All Reports and Data Requested J Yes
Visual inspection Results:
Facade:
Inspected Debris
North ❑ N/A ❑ YesDNo No Visible/Fine Layer i4 to 1' >1'
South ❑ N/A No Visible/Fine Layer 83010
QYesDNo S4to1'
East 9 N/A 13 Yes ❑ No No Visible/Fine Layer DAto1' >1'
West N/A 9Yes9No No Visible/Fine Layer ❑'h to 1' 831.1'
Facade Description: A
Roof
Debris: Visible one Layer . .❑ % to 1' 9>1"
Description: 5 l 10
Setbacks N/A(
Floor:___ . Debris: No Visible/Fine Layer % to 1' 1J> 1'
Floor:___ Debris: No Visible/Fine Layer i4 to 1' >1'
Floor:___ Debris: No Visible/Fine Layer '/4 to 1' > 1'
Floor:_,_ Debris: No Visible/Fine Layer % to 1' >1'
Floor:___ Debris: No Visible/Fine Layer 'A to 1' > 1'
Comments,
Date: Inspection Team: Name: Agency:
Nam: Agency:
NYC-WTC 000128078
OCR can misread numbers and units. Confirm readings against the page image before using them.
NYC-WTC_000128078Source: NYC Law Department, mirrored locally