NYC 9/11 Public Portal Document
JUL-09-2002 12:45
REQUEST FORM FOR INDOOR AIR RESIDENTIAL ASSISTANCE PROGRAM
Name of Resident
Address
Apartment Number;
NewrYorkrNew •Yerit-
Telephone Numbers:
Home
Work
REQUEST
I have read the fact sheet on the Indoor Air Residential Assistance 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
I request monitoring of the Residence.
Initial one of the following:
I request “aggressive” air sampling.
OR
I request “modified aggressive” air sampling.
AGREEMENT
In consideration of the benefits of the Indoor Air Residential Assistance Program, on behalf of myself
and any other occupants of the Residence, I agree to the following;
I consent to employees and authorized representatives of the EPA and the New York City Department
of Environmental Protection (“NYCDEP”) and contractors for NYCDEP having access to the
NYC-WTC_000154136
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