NYC-WTC_000166105

NYC 9/11 Public Portal Document

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-. AFFIDAVIT (CERIIFIGTE-) OF SERVICE . -." - -; . _ _.

State of. P!_w York, County of } as: . _ . . - -

The undersigned being duty sworn' deposes and says: That deponent is not a party to the action and is over 18 years of age; That on son 19_ at AMn- at ., deponent served the within Notice of Violation is Hearing on the respondent named herein: - ; i • _te.. ... . a' • I. Individual; Personal Service -' -- _ -~ - _. _ _ - _ -., 1 _.

Eli by delivering a true copy to said respondent peraonallY_. - - . --- _. T. __:-..,h.).__, -- _ _-`. _ —•' -- _ - _ _. --

IL Individual; Substituted Service 1 i .. ' .Q by delivering a true copy to - --._ . . .. a person of suitable age and discretion. Said premises is responder actual place of busuresA dwelling house or usual place of abode within the State. -

111. Corporation -- _.;'1..=:.._ •.:_: _. ...... - _ -- -. .. ❑ by delivering a true copy to_________________________________________________ at said cotpomtic

IV. Delivery to Employee at Premlees - - - .. ,. by delivering a true copy to respondent's employee at the above location: (answer A and B) '. A. I attempted to personally serve the herein Notice of Violation on the respondent named herein but was unable to do so because, having entered the premises and.havingJdantlp _ myself, I was: _. .. .. . - .. _ -• . - .,' : , - - - 1. Q advised by that the respondent was not then present, and premises is neither respondent's actual place of business rtordwamrlg Itdre

2. ❑ unable to secure Identification of the person(s) present; ._. . . . - __ .. .,. '...•...

3 advised try that no officer, director, managing agent or agent of respondent corporation was present.

B. Thereupon, I delivered a copy of the herein Notice of Violation to sere meow r whom I believe to be an employee of respondent at the premises because: (check 1. 2 or 3) 1. ❑ Employee so identified him/herself. -- _ _ .. - . . -. 2. ❑ Employee was performing work consistent with being employed by the respondent or 3 [3 Other: - -- - - - -- - - - -

Description of Individual. (This must be completed for all types of service except corporate, Number 111, above.) Deponent describes the individual served as follows:- - - -

❑ Male 0 White Skin ❑ Black Hair ❑ 1420 0 Under 5' fl Under 100 ❑ female 0 Black Skin ❑Brown Hair ❑ 2135 _ 0 5'0"5'3• O 100.130 4n 0 Yellow Skin 0 Blond Hair - _ 03650 -_ ❑ 646'8' . Cl 131-180-- 0 Brown Skin 0 Gray.Hair .c . -051-65 _ _ _ _ O-b"98'0' . _ _. _^ 0161.200"' ❑ Red Skin - "- 0 Red Hair _ ❑ Over 65 ❑ Over 6' .. .. . _ 0 Over 200n -. ._ ❑ White Hair . . _. .. ___ . .. - :. .. . .. __ 0 Balding .. _ - .. - - - - . .. Other identifying characteristics- -- J .- _. r--_ :-

Sworn to before me on- - - -. 19~ -, - • 3' -. -. . . - '•c.:'+

1? ' .. -' akvwuw or mane Oman •

• If rot swum, this statement shelf constitute a certificate of service..; . - ► - .. • _ - •-, ~~_~,_j, -,

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NYC-WTC 000166251