WORLD TRADE CENTER - RESIDENTIAL APARTMENTS

NYC 9/11 Public Portal Document

JUL-09-2002 12=45

-3-

include clothing.

I understand that I, or my authorized representative, may be present and observe the cleaning and monitoring activities being performed in the Residence if I choose “modified aggressive” air sampling of the Residence, I understand that if I choose “aggressive” air sampling of the Residence, I may only be present for the cleaning, but not for the “aggressive” air sampling. Following “aggressive” air sam pl ing of the Residence, I understand that neither I nor the occupants of the Residence will be allowed to return to the Residence until the day after completion of “aggressive” air sampling. I, or my authorized representative, agree to comply with health and safety instructions that may be provided by EPA and/or NYCDEP’s contractors for activities in the Residence under the Indoor Air Residential Assistance Program.

I agree that insurance payments and/or any other compensation which I received, or will receive in the future, for activities covered by the Indoor Air Residential Assistance Program at the Residence, and which I have not spent for such purposes, will be paid to the Federal Emergency Management Agency. Instructions for such reimbursement will be provided upon request to EPA.

SAMPLING APPROACH

I understand that if I choose “aggressive” air sampling of the Residence, an electric-powered leaf blower will be used to direct air onto all surfaces and personal property, and one or more oscillating fans will circulate air throughout the areas being sampled.

I understand that if I choose “modified aggressive” air sampling of the Residence, one or more oscillating fans will be used to circulate air throughout the areas being sampled.

I understand that the air will pass through a filter and be sampled. I also understand that wipe samples of surfaces may be collected and analyzed.

I understand that at the conclusion of the investigation, EPA will provide the undersigned with the results of the monitoring of the Residence. Monitoring data in EPA’s data base for the Indoor Air Residential Assistance Program will be made available to the public, but the identity of the participants will be kept confidential.

AUTHORIZED SIGNATURE

I certify that I am authorized to make this request on behalf of all the occupants of the Residence.

Signature Date

Name and Title (PRINT)

TOTAL P.04 NYC-WTC_000154138