NYC 9/11 Public Portal Document
, - VENTILATION SYSTEM EVALUATION FORM
Please complete this form in accordance with instructions in the accompanying guidance document
Dnrf 1 n !_pnpral infnrnoatinn
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ate of evaluation: . J
valuation team (list name an affiliation):
I Building contact name and phone:
(Environmental professional)
; .r rz 1 (HVAC professional)
Building address: Type of Facility (check all that apply):
`yp () V Residential
N' w ~ o r_~ ti _ - Multi-use
Other (describe)
Date of construction:
Number of residents i units: Number of floors: /,'—
Prior inspection report/maintenance records available for review?:
Other comments
Ventilation system types (check all that apply and indicate total no. of units)
Central ventilation system Mechanical exhaust system
Est. no. of units Est. no. of units 3
Mechanical make-up air system Passive shaft/duct
Est. no. of units ~ Est. no. of units
Other (describe)
I certify that to the best of my knowledge, the information and observations recorded on this form
including all attachments are a true and accurate representation of site conditions.
Ventil i st VAC) Evaluator Date ,)/
Par .0 'isual Inspection Forms
Use the attached forms to document visual inspections. Complete the forms in accordance with
instructions in the accompanying guidance document.
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NYC-WTC 000130405
OCR can misread numbers and units. Confirm readings against the page image before using them.