NYC 9/11 Public Portal Document
ALIG-06-2002 12: la FROM DEP LEGAL TO 4422 P.04/06
I
REQUEST FORM FOR WORLD TRADE CENTER INDOOR DUST CLEANING
PROGRAM
Name of Resident
Address
Apartment Number
New York, New York
Telephone Numbers;
Home
Work
REQUEST
I have read foe fact sheet on foe World Trade Center Indoor Dust Cleaning Program (“Program") and
considered foe 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 foe following
cleaning and monitoring alternatives under foe Program.
Initial one of the following:
I request dust cleaning of foe residence identified above (“Residence") and monitoring after foe
cleaning.
OR
I request monitoring of foe Residence.
Initial one of foe following:
I request “modified aggressive" air sampling.
OR
I request "aggressive” air sampling.
AGREEMENT
In consideration of foe benefits of foe Program, on behalf of myself and any ofoer occupants of foe
Residence, I agree to foe following;
I consent to employees, aufoorized representatives and contractors of foe EPA and foe New York
City Department of Environmental Protection ("NYCDEP") and contractors for NYCDEP having
NYC-WTC_000148071
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