NYC 9/11 Public Portal Document
JUN-2110: lb
REQUEST FORM FOR INDOOR AIR RESIDENTIAL ASSISTANCE PROGRAM
Name of Resident
Address
Apartment Number:
New York, New York
Telephone Numbers:
Home
Work
REQUEST
Initial one of the following:
I request dust cleaning of the residence identified above (“Residence”) and monitoring afterwards
to confirm that asbestos is not present above cleanup levels.
OR
I request monitoring of the Residence.
Initial one of the following:
I request “aggressive” air sampling, as described below.
OR
I request “modified aggressive” air sampling, as described below.
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 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 of the Robert T. Stafford Disaster
Relief and Emergency Assistance Act, 42 U.S.C. § 5121 ^.seg,
NYC-WTC_000154140
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