WTC environmental assessment form, building contamination checklist

NYC 9/11 Public Portal Document ems...._

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" WTC Visual Survey Form Premise Address:

Block: Residential 0 Commercial Y Name of Building: Lot: Mix Use Other # of Stories: AKA's: emu -\ ,— 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 North ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑Yto1" 0>1" South ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑'/to1" 0>1" East ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑Yto1" 0>1" West ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑'/tol" 0>1" Facade Description:

Roof

Debris: ❑ No Visible /Fine Layer ❑'/ to 1" Description:

Setbacks N/A ❑ Floor: I Debris: ❑ No Visible/Fine Layer ❑'/ to 1" ❑ > 1" Floor: Debris: ❑ No Visible/Fine Layer 0¼ to 1" ❑ > 1" Floor: Debris: ❑ No Visible/Fine Layer ❑'/2 to 1" ❑ > 1" Floor: Debris: ❑ No Visible/Fine Layer 0¼ to 1" ❑ > 1" Floor: Debris: ❑ No Visible/Fine Layer ❑ % to 1" ❑ > 1"

Comments

Date: Inspection by: Name: Agency: V "r Name: Agency:

NYC-WTC 000128476