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 In or ation
Date of evaluation: 2. o3 - Building contact name and phone:
Evaluation team(list name and affiliation):
. pt,UG- Du s 'i~2 (Environmental rofessii
Boa • ~a-~,c -(HVACprdfessional)
• Building address: Type of Facility (check all that apply):
ci . )(Residential
Goa
Multi-use .
S .
Other describe
Date of construction:
Number of residents 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 39
• Mechanical make-up air system Passive shaft/duct
• Est. no. of units Est. no. of units ______.-_
:: Other (describe) •.
and observations recorded on this form
I certify that to the best of my knowledge, the information
including all attachments are a true and accurate representation of site conditions.
Vent! t' n S st AC) Evaluator 0 Date
l2no.3
P .0 sal Inspection Forms. .
•
the forms in accordance with
Use the attached forms to document visual inspections. Complete
Instructions in the accompanying guidance document.
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NYC-WTC 000133922
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