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FORM LETTERS

Label derived from the City's folder field. The City does not supply document titles.NYC-WTC_000150190–000150197
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NYC 9/11 Public Portal Document i-iUb-UD-iak3^ rKui'i tier ucumu 1U r • UHx K/o

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 ■i I J 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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NYC-WTC_000150193Source: NYC Law Department, mirrored locally

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