NYC 9/11 Public Portal Document
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REQUEST FORM FOR WORLD TRADE CENTER INDOOR DUST CLEANING
PROGRAM
Name of Resident
Address
Apartment Number
New York. New York
1
Telephone Numbers:
Home
Work
REQUEST
I have read the feet 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 of the following:
I request dust cleaning of the residence identified above (“Residence") and monitoring after the
cleaning.
OR 5
I request monitoring of the Residence.
Initial one of the following: !
I request “modified aggressive* air sampling.
OR
I request “aggressive" air sampling.
AGREEMENT
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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 the New York
City Department of Environmental Protection ('NYCDEP") and contractors for NYCDEP having
NYC-WTC_000150193
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