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Resident request form for WTC indoor dust cleaning program, 2002

Machine-extracted title · confidence 100%

Application form allowing residents to request dust cleaning and air monitoring services under the World Trade Center Indoor Dust Cleaning Program.

NYC-WTC_000140939–000140941

Folder label: “FEMA SEMO

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Scanned page image, NYC-WTC_000140939
OCR text

OCR status: ok · source: pdftotext

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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NYC-WTC_000140939Source: NYC Law Department, mirrored locally

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