NYC 9/11 Public Portal Document
VENTILATION SYSTEM EVALUATION FORM
Please complete this form in accordance with instructions in the accompanying guidance document
n..... 1 n C_Pnera1 lnfnrmatinn
• ')ate of evaluation: O3 I Building contact name and phone:
Evaluation team (list name and affiliation):
(Environmental professional)
- Ac-s IA +~~ (HVAC rofessional)
Building address: Type of Facility (check all that apply):
t" A' 1 S Residential
art ic_ Multi-use
Other (describe)
Date of construction:
Number of residents 1 units: Number of floors:
Prioi 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 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 AC) Evaluator Date
Pa nspection Forms
.21yv3
Use the attached forms to document visual inspections. Complete the forms in accordance with
instructions in the accompanying guidance document.
NYC-WTC 000135793
OCR can misread numbers and units. Confirm readings against the page image before using them.