NYC 9/11 Public Portal Document
1
REQUEST FORM FOR WORLD TRADE CENTER INDOOR DUST CLEANING
PROGRAM
Name of Resident
Address «
Apartment Number:
New York, New York
Telephone Numbers:
Home
/
Work
REQUESt
I have read the fact sheet on the WorM Trade Center Indoor Dust Cleaning Program (“Program”) and
considered the information provided tbine by the U.S. Environmental Protection Agency (“EPA").
Having.considered the cleaning and monitoring offered, I would like to participate in the following
cleaning and monitoring alternatives under the Pegram.
Initial one of the following:
I request dust cleaning of the residence identified above (“Residence”) and monitoring after the
cleaning.
OR
I request monitoring of the Residence.
Initial one of the following:
I request “modified aggressive” air sampling.
OR
I request “aggressive" air sampling.
AGREEMENT
In consideration of the benefits of the Program, on behalf of myself and any other occupants of the
Residence, I agree to the following:
NYC-WTC_000140939
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