WTC environmental assessment form, building contamination checklist

NYC 9/11 Public Portal Document

WTC Visual Survey Form Premise Address: i 1 , _-•

L - -- Block: t5 c..

Residential 0 Commerci Plant, of ildi g: A. Lot: Mix Use Other # of Stories: 1. AKA's: Building Owner anagement: 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 0 No Locations: ACM Clean Up ❑ Yes ❑ No Locations: Air Monitoring ❑ Yes ❑ No Locations: Copies of All Reports and Data Requested j Yes Visual Inspection Results: Facade: Inspected Debris ❑ N/A ❑ No Visible/Fine Layer to 1" North South East ❑ N/A ❑ N/A D YesDNó Yes ❑ No ❑Yes❑No ❑ No Visible/Fine Layer 0 No Visible/Fine Layer ❑'s ato1" O%to1" 0>1" ❑>1" 0>1" West ❑ N/A Yes❑No ❑ No Visible/Fine Layer "z to 1" 0>1" Facade Description:

Roof ('V

Debris: Flo Visible ine Laye []' 10 1" > 1" Description I { 0

Setbacks N/A [] Floor: Debris: ❑ No Visible/Fine Layer ❑ Va to 1" 0> 1" Floor: Debris: ❑ No Visible/Fine Layer 0 h to 1" ❑ > 1" Floor: Debris: ❑ No Visible/Fine Layer 0 a to 1" ❑ > 1" Floor: Debris: ❑ No Visible/Fine Layer ❑ % to 1" ❑ > 1" Floor: Debris: 0 No Visible/Fine Layer ❑ % to 1" ❑ > 1" Comments

Date: Inspection Team: Name: C- Agency: « J

Name: Agency:

NYC-WTC 000128477