NYC 9/11 Public Portal Document
VENTILATION SYSTEM EVALUATION FORM
Pleas u omplete this form in accordance with instructions in the accompanying guidance document
Part General Information
Date evaluation: Building contact name and phone:
Evali' jn team (list name and affiliation):
(Environmental professional)
(HVAC professional)
Build ' address: Type of Facility (check all that apply):
2] Residential
d Multi-use
d Other (describe)
Date construction:
Numb of residential units: Number of floors:
Prior : ipection report/maintenance records available for review?:
Othe .mments
Vent ion system types (check all that apply and indicate total no. of units)
EH C. :ral ventilation system □ Mechanical exhaust system
i no. of units Est. no. of units
□ N hanical make-up air system d Passive shaft/duct
r no. of units Est. no. of units
□ C er (describe)
I cer that to the best of my knowledge, the information and observations recorded on this form
inclu ag all attachments are a true and accurate representation of site conditions.
Vent: ion System (HVAC) Evaluator Date
Part Visual Inspection Forms
Use attached forms to document visual inspections. Complete the forms in accordance with
instrs. dons in the accompanying guidance document.
NYC-WTC_000161585
OCR can misread numbers and units. Confirm readings against the page image before using them.