NYC 9/11 Public Portal Document
Please complete this form In accordance with Instructions In the accompanying guidance document
irart i.0 tieneral information
Date of evaluation: t/i.3fc 3 I Building contact name and phone:
Evaluation team (list name and affiliation):
; a (US: t 7N[~t,'1 +4 (Environmental professional)
.- 71 . VAC professional)
Building address: I Type of Facility (check all that annlv):
Ur 2 t- w Multi-use
Other (describe)
Date of construction:
Number of residents units: .ZS Number of floors: 5
Prior inspection report/maintenance records available for review?:
IJv
f 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
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.
Ventil io Sy to Y'AC) Evaluator' ate.
J
•1 I
l/ 3
Part \ isu Inspection Forms 4
Use the attached forms to document visual inspections. Complete the forms In accordance with
Instructions in the accompanying guidance document.
NYC-WTC 000135493
OCR can misread numbers and units. Confirm readings against the page image before using them.