NYC 9/11 Public Portal Document
REQUEST FORM FOR WORLD TRADE CENTER INDOOR DUST CLEANING
PROGRAM
Name of Resident
Address •
Apartment Number:
New York, New York
Telephone Numbers:
Home
/
Wo&
REQUEST
I have read the fact sheet on the W^)d Trade Center Indoor Dust Cleaning Program (“Program”) and
considered the information provided to jtne 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 “modified aggressive” air sampling.
OR
I request “aggressive” air sampling.
AGREEMENT
In consideration of the benefits of the Program, on behalf of myself and any other occupants of the
Residence, I agree to the following:
NYC-WTC_000154375
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