NYC 9/11 Public Portal Document
SEP-05-2002 15:02 FROM DEP LEGAL TO 4422 P.02i06
REQUEST FORM FOR WORLD TRADE CENTER INDOOR DUST CLEANING PROGRAM
Name ofResident
Address
Apartment Number:
New York, New York
Telephone Numbers:
Home
Work
REQUEST
I have read the fact sheet 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, I would like to participate in the following
cleaning and monitoring alternatives under the Program.
initial one the £o]lowing
I request dust cleaning of the residence identified above ("Residence") and monitoring after the
cleaning.
OR
I request monitoring of the Residence.
Initial one of the followini.
I request "modified aggressive" air sampling.
OR
I request "aggressive" air sampling.
AGREEMENT
In consideration of the benefits of the Program, on behalf of myself and any other occupants of the
Residence, I agree to the following:
I consent to employees, authorized representatives and contractors of the EPA and contractors of the
New York City Department ofEnvironmental Protection (` NYCDEP") having access to the Residence
NYC-WTC 000148063
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