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WTC dust cleaning program access forms revision, August 2002

Machine-extracted title · confidence 80%

Distribution of revised EPA access forms for WTC dust cleaning program with minimal substantive changes from previous version.

NYC-WTC_000163314–000163319

Folder label: “E-mails M. Gilsenan

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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

Work

REQUEST

I have read the fact 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 abo\e (“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 Prog-am, on behalf of myself and any other occupants of the Residence, I agree to the following:

I consent to employees, authorized representatixes and contractors of the EPA and the New York City

NYC-WTC_000163315

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NYC-WTC_000163315Source: NYC Law Department, mirrored locally

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