NYC 9/11 Public Portal Document
WTC Visual Survey Form r ,
Premise Address:
Block:
Lot:
Residential
Mix UseD Other
d
Commercial Name of Building:
# of Stories: AKA's:
Telephone Number:
II
Building Owne,IM n emen
Name: FAX: .-.-.-.-.-.-.-.-.-.-.-.-.-. .-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.
Address:
On Site Contact:
Name: * ' Telephone Number:
Building Owner Management Activities
Interior Survey Performed Q Yes-ONO
Exterior Survey Performed ❑ Yes o
General Clean Up, es Q No Locations:
ACM Clean Up ❑ Yes (No Locations:
Air Monitoring ❑ Yes J No Locations:
Copies of All Reports and Data Requested 9 Yes
Visual Inspection Results:
Facade:
Inspected Debris
North bf4UA ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑Mato l" 0>1"
e❑
South /A Yes ❑ No ❑ No Visible/Fine Layer ❑14to1" 0>1"
East ON/A s ❑ No ❑ No Visible/Fine Layer ❑Y:to 1" 0>1"
West N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑%tol" ❑>1"
Facade De n :
Roof
Debris: Visible /Fine Layer ❑ Y to 1" 0>1"
Description:
Setbacks N/A ❑
Floor Debris: ❑ No Visible/Fine Layer ❑ Y to 1" ❑ > 1"
Floor. Debris: ❑ No Visible/Fine Layer 0
V to 1" ❑ > 1"
Floor: Debris: ❑ No Visible/Fine Layer ❑ Y. 1"
to ❑ > 1"
Floor. Debris: ❑ No Visible/Fine Layer ❑ Va to 1" ❑ > 1"
Floor. Debris: 0 No Visible/Fine Layer ❑ h to 1" ❑ > 1"
Comments (qo¼,%. \Lc (L Q
QA, k
Date: /=002 Inspection Team: Name: Agency:
ENTERED Name: Agency:
NYC-WTC 000128615
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