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: I ir v3 I Building contact name and phone: 2'a iJj
Evaluation team (list name and affiliation):
V,ci t. ~ Lx • AZ A cV 4r, n Ewt. (Environmental professional)
. . -f ALf _ -:.- ru s EAS (HVAC professional)
Building address: Type of Facility (check all that apply):
Yµ EN v~. , Residential
w K. Multi-use
Other_(describe)
Date of construction:
Number of residents units: /v 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 O ' Est. no. of units , 14
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.
Ve on y to VAC) Evaluator' Dat
2. \ Isual Inspection Forms
Use the attached forms to document visual inspections. Complete the forms in accordance with
Instructions in the accompanying guidance document.
NYC-WTC 000135523
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