NYC-WTC_000166105

NYC 9/11 Public Portal Document

Instructions to Inspectors—All boxes # .his form must have an answer. Answers v a "NO" answers to a "V" mandate a Violation Order, "NO" answers to a "*" mandate automatic failure. Check "YES" "NO" or "N/A". ON SITE EXAM FOR FIRE SAFETY DIRECTOR-OFFICE Z 01 6 Ge nspector Lam_

Name of Candidate / //45L n ~ 1 Office Addross ~ ~✓ ~ ~ G —"_~ Date of Examination ' (Print last name, first name) " 'C A: N ~. Instructions to Inspectors--if any asterisk (*) items are marked "NO", terminate the test immediately. See Section VIII for further information. I. Physical Requirements—Does candidate have ability to: 1 YES I NO f N/A

*A. Speak and understand English? B. Hear spok words over a telephone? I C. Possess npessary vision? (with co ctive devices) (correcti devices acceptable) Yes No ❑ J Yes No ❑ Yes ❑ I 111t1 B: Buildina Instructions to Inspector--If any violation (V) Items are marked "NO", issue a Violation Order at the end of the Test. Test must proceed. II. Records: v. A. Fire jYecords current? v. B. Firem s Service Elevator Test Records current?J v. C. Keys ke Fire Command Station. Yes LJ No ❑ Yes Li No ❑ N/A ❑ Yes NoLI N/A [1 v. D. Fire Safety Ian and building 10 V. E. A current list of all floor Wardens and phone v. F Master window keys available? plan atjife Command Station? numb at Fire Command Station? Yesl,k No❑ YesLJ No❑ Yes No❑ N/A v. G. Building current in actual Fire Drills? (*if over 3 months) Yes No ❑ TOTAL (7) G I Instructions to Inspector—If any violation (V) items are marked "NO", issue a Violation Order at the end of the Test. Test must Proceed. 111. a. Specific Building Inspection: L/ Special Instructions—Choose one floor for the general floor inspection FLOOR Building Inspection—Signs and Charts— v. A. Are st ays roperly lettered? v. B. Are ,f~lo9rS properly numbered? v. C. Is floor diagram-~'_ osted? Yes No ~ Yes E N0 ❑ Yes Q~Nor` v. D. Are stairways re-entry v. E. Are elevators properly lettered on each v. F. Is floor diagram property oriented? -- —^ si n osted? elevato ank? Yes No ❑ N/A ❑ Yes TV No ❑ NIA ❑ Yes 0 No [ + v. G. Is elevator sign "In Case of Fire, v. H. Are exit doors unlocked, closed and v. 1. Fire Drill Organization Charts Use Stairs" posted? unobstruct ? poste_ d current? 3 Yes No ❑ N/A ❑ Yes ❑ o❑ Yes [_J No ❑ TOTAL (9) Ill. b. Building Inspection—Signs, and Charts—Choose one floor for the general floor inspection b

v. A. Are st ays properly lettered? v. B. Are floors properly numbered? v. C. Is floor agram posted? Yes t No ❑ Yes No ❑ YesL i No ❑ v. D. Are stairways re-entry v. E. Are elevators properly lettered on each v. F. Is ram properly oriented? si n posted? elevator bank? 3 YesZ No❑ N/A [1 Yes a No❑ N/A❑ Yesfl?~No ❑ v. G. Is elevator sign "In Case of Fire, v. H. Are exit doors unlocked, closed and v. I. Fire Drill Organization Charts Use Stay" posted? unob7~slr cted? posted-nd current? Yes 0' No❑ N/A❑ YesLI No❑ Yes [1 No Li TOTAL (9) IV. Instructions to Inspector—if four (4) or more Items below are marked "NO", the inspector must issue a Violation Order at the end of the test. Test must proceed. This next part must proceed with contacting a Floor Warden within the Building. Read the following statement to the Warden='In the event of a fire on this floor, explain which specific actions must be taken by you." FLOOR WARDENS:

NAME OF FLOOR WARDEN CONTACTED FLOOR CHOSEN TELEPHONE NUMBER

Does Floor Warden have knowledge of: ______—

A. Position urin fire drill or emergency? B. Notiticat procedures? C. Locatia alarm boxes? Yes L No~ Yes LS No ❑ Yes Li No ❑ N/A ❑ D. EvacuatprI location? E. Evacu n procedures? F Numrb~el'6) exits on floor? JG. Examen for exits on floor? ~r Yes LA' No ❑ J Yes J No ❑ Yes U No ❑ Yes No L) H. Reporti whether smoke or Fire? I. Duties o Depuxt Fire Warden and Searchers? v. J. Were fire drills conducted? Yes LT No ❑ Yes No U Yes ❑Y No [1 *K. Floor wardens in numerous floors properly trained? Yes No U TOTAL (11) Section B: (II, III, IV) 8 or more answered "NO" In Section B fails. SECTION B TOTAL (36) Number of correct answers in this section is Number of incorrect answers is . Number of N/A answers is M25-14 ,B- 70250.3.R25-P

NYC-WTC 000166262