EPA HOTLINE

NYC 9/11 Public Portal Document

ATTACHMENT 1

DRAFT HOTLINE QUESTIONNAIRE

First Name: Middle Initial: Last Name: Street Address: Apartment/Suite Number: Floor: ZIP Code: Cross Street #1: Cross street #2 Mailing Address (if different)' Street/Box: ZIP Code Entry Information (doorman, buzzer?): Telephone, Daytime: Telephone, Evening: Telephone, Fax: Telephone, Cell: email: Communicate by mail or email: Confidentiality Code:

Number of rooms: Central air conditioning: Unit air conditioning (number and location of units): Carpets/Rugs (number, location and type): Describe the dust situation when you first entered your apartment: Light: Write in it: Measurable depth (estimate): Color: Was your apartment first cleaned by: Certified asbestos contractor (name): Approximate date: Non-certified contrrctor: Approximate date: Housekeeper: Approximate date: Occupant: Approximate date: If contractor, hired by building owner/manager or you: Was your apartment tested before and/or after cleaning: Approximate date: What were the test results: Before: After: Were building common areas cleaned:

Do you want: Your apartment professionally cleaned and tested for asbestos in air (after cleaning): (This will take 2-3 days and will require you or your representative to be present)

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