DEP 59.17 Junction Blvd, 11th FL

NYC 9/11 Public Portal Document

“ToP

DRAFT HOTLINE QUESTIONNAIRE (& POST-SURVEY FIELD INFO)

QUESTIONNAIRE:

First Name: f- CTast Name:j---- - “ AK4-. Street Address: Apartment Number: Cross Street #1: Cross street #2: Telephone, daytime: Telephone, evening: emaih i

Number of rooms: Central air conditioning: Unit air conditioning (# unit^: ___ ah A Carpetst___ f b Describe the dust situatiori when you first entered your apartment? Light: (^rite'^p/i^'^ Measurable depth (estimate): o ... Was your apartment first cleaned by: O “5JC^ified asbestos contractor (name): Approximate date: ©Non-certified contractor: , « , . Approximate date: J’ ** V Housekeeper?*^ ft- V '^Approximate date: Occupant: * Approximate date: Was your apartment tested^ y,. -bo ai^i/o *■ a+bfr Approximate date: Do you know the results: ' *‘2 *» Were building conunon a,v ie A,

Do you want: ------------ n k Your apartment professionally cleaned and tes:^fafter cleaning): 0 Q (This will take 2-3 days a.xd will require you p . or your representative to be present) MI k b6u44 vvMhT Yom- apartment tested/without cleamng: (If - and only if - asbestos is found during testing, you may still ask that your apartment be professionally cleaned.) for a HEPAxvaUuui^ (YOU may feeeWalffiPA vacuum even if you have your\ ' o- apartment professionally cleaned)ND. Is this luiiucT? /

Post-Interview fields: Y* Is Cleanup scheduled (date): Entry notes: IW’.Votc

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