NYC 9/11 Public Portal Document
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REQUEST FORM FOR INDOOR AIR XtESIDENTLAL ASSISTANCE PROGRAM
Name of Resident
Address
Apartment Number:
New York, New York
Telephone Numbers:
Home
Work
REQUEST
Initial one ofthe followin
afterwards
I request dust cleaning ofthe residence identified above("Residence")and monitoring
to confirm that asbestos is not present above cleanup levels.
OR
I request monitoring ofthe Residence.
initial one ofthe following..
I request"aggressive" air sampling,as described below.
OR
I request "modified aggressive" air sampling, as described below.
AGREEMENT
In consideration ofthe benefits ofthe Indoor Air Residential Assistance Program, on behalf of
myselfand any other occupants ofthe Residence,I agree to the following:
I consent to employees and authorized representatives ofthe United States Environmental
Protection Agency("EPA")and the New York City Department of Environmental Protection
("NYCDEP")and contractors for NYCDEP having access to the Residence and the personal
property in the Residence,as necessary,to conduct dust cleaning and monitoring activities. I
understand that these activities are to be performed in accordance with the roles of EPA and
NYCDEP under the Federal Response Plan and the authority ofthe Robert T. Stafford Disaster
Relief and Emergency Assistance Act,42 U.S.C.§ 5121 et M
NYC-WTC 000148075
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