NYC 9/11 Public Portal Document
VENTILATION SYSTEM EVALUATION FORM -
.Please complete this form in accordance with Instructions In the accompanying guidance document
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Date of evaluation: i 2 2 03 Building contact name and phone:
Evaluation team (list name and affiliation):
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S (Environmental professional)
(HVAC professional)
Building address: Type of Facility (check all that apply):
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Residential
v•q, Multi-use
Other (describe)
Date of construction: .
Number of residents units: 300 Number of floors:
Prior inspection report/maintenance records available for review?:
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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 9 Est. no. of units
Passive shaft/duct
Mechanical make-up air system
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.
Ventilatf n ys e VAC) Evaluator Date
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Part .0 '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 000135912
OCR can misread numbers and units. Confirm readings against the page image before using them.