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 Part 1.0 General Information Date of evaluation: I /2.21O3 I Building contact name and phone: Evaluation team (list name and affiliation): moo...+y 6:4 t bu cY uSi`4lz5 (Environmental professional) (HVAC professional) Building address: Type of Facility (check all that apply): F" t.; v - 5T. .Residential w v~L. st_ t'i Multi-use Other (describe) Date of construction: Number of residents units: 300 Number of floors: Prior inspection report/maintenance records available for review?: 00 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_9 Est. no. of units Mechanical make-up air.system Passive shaft/duct

Est. no. of units Est. no. of units 2 - 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.

Ventilaff n ys e VAC) Evaluator' Date

Part .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 000132758