4 WTC Visual Survey Form
Premise Address: ~ ~ C• I
T 3
Block: Residential J Commerci Name of Building:
Lot: Mix Use D Other
# of Stories J AKA's:
Building Own 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 ❑ 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 J Yes
Visual Inspection Results:
Facade:
Inspected Debris
North ❑ N/A ❑ Yes 0 No ❑ No Visible/Fine Layer ❑Y2to1" ❑>1"-
South ❑ N/A ❑ Yes 0 No ❑ No Visible/Fine Layer ❑Yato l" 0>1"
East ❑ N/A 'Yes 0 No 'No Visible/Fine Layer ❑Y2to 1" 0>1"
West ❑ N/A , 'es O No [3No Visible/Fine Layer 0 %2 to 1" 0>1"
Facade Description:
Setbacks N/A 0
Floor. Debris: 0 No Visible/Fine Layer 0 V to 1" ❑ > 1"
Floor. Debris: 0 No Visible/Fine Layer ❑ Va to 1" ❑ > 1"
Floor: Debris: 0 No Visible/Fine Layer ❑ Va to 1" ❑ > 1"
Floor: Debris: 0 No Visible/Fine Layer ❑ Y to 1" ❑ > 1"
Floor. Debris: 0 No Visible/Fine Layer 0 % to 1" ❑ > 1"
Department of Environmental Protection inspection form for WTC-area building documenting facade condition, asbestos, and other environmental hazard assessments.