DEP operator referral form for WTC site, undated

NYC 9/11 Public Portal Document

Date:.s Time: ) t.,t Name of Operator _

Cate: (circle one)

vironrnent Cleaning Health Indoor Air

School Old WTC Other Specific Contaminant

QuesUon Cv/Zt/ mil_

1 27n- Ci 8 F /-_ /-e3é) )Z '

Answer: d -

1J)j ['alter Information: ~J J Last Name: / ~_ 70 First Name•

Address 1: . Apt_)

Address 2: Borough:

City State: _ Zip:

Phone #1 ( % Phone #2 L

Follow un:

ReferrallFollow-Up Needed? (circle one) NO ( )

Referral Agency/Organization:

DEP Reference #

NYC-WTC 000147168