NYC 9/11 Public Portal Document
Please complete this form In accordance with Instructions in the accompanying guidance document
Part 1.0 General Information
Date of evaluation: 1/1.3/0 Building contact name and phone:
Evaluation team (list name and affiliation):
° ti ' (Lis: &U-t1- T* -#.ii , 4 (Environmental professional)
•- 71 .;; t ,_;c; F VAC professional)
Building address: Type of Facility (check all that apply):
.
v co c.r esidential
Ur- 2 tc. lV Multi-use
Other (describe)
Date of construction:
Number of residents units: .Z51 Number of floors:£5
Prior inspection report/maintenance records available for review?:
'Jo
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 J
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 1Sy to )'AC) Evaluator pate.
1
•
/~ I
Part '4 isu Inspection Forms
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.