Ventilation System Evaluation Form Part 1, WTC Dust Cleaning, Oct

NYC 9/11 Public Portal Document

VENTILATION SYSTEM EVALUATION FORM Part 1.0 General Information Date of Evaluation: I Building contact name and phone:

Evaluation Team (list name and affiliation): (Environmental Professional) (HVAC/Electrical Professional) (Sheet Metal Professional) Building Address: Type of Facility (check all that apply): n Residential ri Multi-use n Other (describe) Number of residential units: Number of floors: HVAC System Types (check all that apply) Il Unit ventilator (single residence unit) [~| Wall/window AC unit (single residence unit) Q Fan coil unit (single residence unit) fl Central ventilation system n Beat pump unit fsingle residgnce unit) r*1 Passive""shaft/duct o Other (describe) Location of outside air intake; Outside air intake accessible for inspection Y N (explain) Part 2.0 Checklists 2.1 Ventilators, wall air conditioning units and window air conditioning units in common spaces Ventilation System Identification: Location: Access adequate for inspection of components: Dust/Dirt / Debris I Suspect WTC-Related Dust System Component Substrate Material (sheet metal wrapped) Light Heavy Present? Estimate % of total dust System Components (sheet metal lined) None (<l/!6 inch (a 1/16 inch (fiberglass) depth) (Y/N) loading depth (flexible connector) (double walled) Outside air intake louvers, grates and/or screens Outside air duct Outside air damperfs) Return air grille Return air plenum Filter rack Filter media Coils (evaporator) ’ Blower assembly Condensate drain pan in-line electrical resistance strip heaters (in supply ducts connected to unit ventilators) Fire dampers Turning vanes Supply air plenum or supply duct Supply air plenum or supply duct liner Supply air diffuser

2.1 Ventilators, wall air conditioning units and window air conditioning units in common spaces (cont.)

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