Ventilation System Evaluation Form, Nov 2003

NYC 9/11 Public Portal Document

VENTILATION SYSTEM EVALUATION FORM *Please complete this form in accordance with instructions in the accompanying guidance document 'i .e 1 A Cnnorsal Tnfnrmafinn , Date of evaluation: t 2v o Building contact name and phone: Evaluation team (list name andaffiliation): • _ ,pug, D u $ (Environmental professional) AC professional) Buildingaddress: Typo of Facility (check all that apply): .• L1 ;-; )Residential •• • Multi-use . .. Other (describe) Date of construction: Number of residents units: Number of floors: Prior inspection report/maintenance records available review?: for

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 39 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.

Vents t n S st AC) Evaluator' Date J2o 0.3 P .0 s al Inspection Forms Use the attached forms document visual inspections. Complete the forms in accordance with to

Instructions In the accompanying guidance document.

NYC-WTC 000132713