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 Inlor;nation
)ate of evaluation: 24sJ0 I Building contact name and phone:
Evaluation team (list name and
'rs'CJ c . . .
D c.— 1.)" s s (HVAC professional)
Building address: Type of Facility (check all that apply):
q la i ,j w ►c.e- Sr 4.esidential
v!Lic... Multi-use
Other (describe)
Date of construction:
Number of residential units: Number of floors: i
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 7 Est, no. of units d G
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' u s AC) Evaluator •
DJ/
ate
Pa .0 Vi ual Inspection Forms
Use the attached forms to document visual inspections. Complete the forms in accordance with
instructions in the accompanying guidance document.
NYC-WTC 000133723
OCR can misread numbers and units. Confirm readings against the page image before using them.