DEP referral form for Old WTC site with handwritten notes

NYC 9/11 Public Portal Document

IW3 Name of Operator. ^gu^cb-rif _ Date: . Time: I

2 (circle one) Environment Cleaning Health Indoor Air

Specific Contaminant School OldWTC Other

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Calter Information;

First Name: _ Address 1: J Pll Address 2:__________ Borough:Qj/W

City State: I^X Zip: ..-.J Phone#2C Phone ----- Vjfcc VcwJUawi 'j . plf J UvaJLi/X fLi'cJ^o^ Follow no: Referral/Follow-Up Needed? (circle one) \YES NO

Referral Agency/Organization; &vrcH DEP Reference #

NYC-WTC_000146946