WTC building inspection checklist form

NYC 9/11 Public Portal Document

WTC Vlsuat Survey Form Q~) toc, ,I ~- Premise Address: ~ r 3 l2S Block: "fc 0 Residential 0 CommercWl J Name of Building: Lot: O Mix Use Other # of Stories: AKA's: 303 - o'7 Ga-ce s tcf.( I I') - t Li4 e"e- I I$ -t7 CMi Building Owner/Management: Telephone Number. ( ) Name: FAX: Address: On Site Contact: Name: " ' Telephone Number: Building Owner Management Activities Interior Survey Performed ❑ Yes ❑ No Exterior Survey Performed ❑ Yes ❑ No General Clean Up ❑ Yes ❑ No Locations: ACM Clean Up ❑ Yes [] No Locations: Air Monitoring ❑ Yes ❑ No Locations: Copies of All Reports and Data Requested Yes

Visual Inspection Results: Facade: Inspected Debris North ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑%to1" 0>1" South ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer 0%to1" 0>1" East ❑ NIA ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑%to1" 0>1" West ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑Yato1" 0>1" Facade Description:

Roof

Debris: ~,No Visible /Finetayer ❑ V to 1" ? =~"'~ ❑ > 1"

Setbacks N/A ❑ Floor Debris: ❑ No Visible/Fine Layer ❑ 1A to 1" ❑ > 1" Floor. Debris: ❑ No Visible/Fine Layer ❑ V2 to 1" ❑ > 1" Floor Debris: ❑ No Visible/Fine Layer ❑ Yz to 1" ❑ > 1" Floor. Debris: ❑ No Visible/Fine Layer ❑ % to 1" ❑ > 1" Floor. Debris: j] No Visible/Fine Layer ❑%% to 1" ❑ > 1"

Comments

Date: Inspection Team: Name: ''— - Agency: Name: Agency: 'I NYC-WTC 000134656