Building representative request form for WTC indoor dust cleaning program,

NYC 9/11 Public Portal Document

REQUEST FORM FOR WORLD TRADE CENTER INDOOR DUST CLEANING PROGRAM

Name of. Authorized Building Representative

Address

New York, New York

Telephone Number: .

REQUEST

As authorized representative for the Building, I have read the fact sheets (Cleanins and Testing Fact Sheet, Comfnon Area and HVAC) on the World Trade Center Indoor Dust Cleaning Program (“Program”) and considered the information provided to me by the U.S. Environmental Protection Agency (“EPA”). Having .considered the cleaning and monitoring offered, the Building would like to participate in the following cleaning and monitoring alternatives under the Program. / ’ \

Initial one' of the following: \

I reques^dust cleaning of the Building identified above and monitoring after the cleaning.

OR

I request monitoring of the Building.

AGREEMENT

I consent to employees, authorized representatives and contractors of the EPA and and contractors of the New York City Department of Environmental Protection (“NYCDEP”) having access to the Building and the personal property in the Building, for as long as necessary to conduct dust cleaning and monitoring activities. I understand that these activities are to be performed in accordance with the roles of EPA and NYCDEP under the Federal Response Plan and the authority of the Robert T. Stafford Disaster Relief and Emergency Assistance Act, 42 U.S.C. § 5121 et seq.

I agree to inform the Project Monitor at the scheduling meeting of any building rules that are applicable to the Program, including, for example, time restrictions, appropriate entrances to the building, and elevator usage. I agree to notify the Project Monitor as early as possible, but no later than three business days, before the scheduled date for the work in the Building, if it is necessary to cancel the date for the cleaning and monitoring activities.

I understand that the cleaning and monitoring will be performed by contractors retained by NYCDEP. I also understand that the contractors performing cleaning and monitoring activities are required to maintain insurance coverage for commercial general liability, workers compensation and environmental impairment liability related to this work, and that they are also bonded to cover loss by theft or destruction of property. The contractors are required to maintain such insurance at all times that they are conducting cleaning and monitoring activities in the Building.

NYC-WTC_000140942