NYC 9/11 Public Portal Document
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State of New Mak, County of
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The underaigned being duly awom* depoaee and aaye: That deponent la not a party to die acdop and to overW yaara of age) Thal on j, at AM/PM
7“^ /i //'Y / 0^ daponent aarved the wHMn Nodoe of Vtatadon and
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Hearino on ttta wapondant named herein.
I. Individual; Reieonal Satvtoe LJ .! r i v/A i ! : ! J L.. □
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Q by delivering a;tnie copy to e^ reepondent peraonaHy. j ! I, U.l_l. 1. Ll JJ J U Kj
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II. Individual; Subat^uM Service, । , , ' I i i ' । j j i □j j i
□ by delivering’ a tnia oopy to' J__ :-----i ---------------
i j—'------ dhtiedon. Said promtoae la reapondant'*
ao<uafptooa'of,lNMiri^'«to««ng./iouMoiru^plaMofabodewl^^d^ j’ j" j* y L L j
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III. Corporation - Una. .. - ........... - ....
□ by dallvaring a true copy tn ' ataaldcorporation.
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IV. mfy><0 Employs* at Prsfflisao
by delivering a trM. oopy to reappndanl'a employea at die above locaHon: (anawar A and B) vi ■
A. I attempled to poraonaHy eerwe the herein Notioe o( Violation on the reepondent nained herein but waa unpbte to do ao beoeuee. havino entored tiMLpratniaba ^ hevina identified
myaelf, I waa:
1. Q adviaedby that toe reaportdent waa r^t than praaani, arrd pramlaaa la naMhar reapondantla aotupl pleoo pi buiinaae nor dwaWng houae.
2. Q unable to aecuie UantHIcalton o( the peiaan(4 preaent;
a □ adviaedby that no offloer, dlraotor, managing agant or agent of riaapondant oorporaUon waa preaent.
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B. Thereupon, I defivered a oopy o( the herein Notioe of VlolaUon to
whom I believe to be an ontotoyee of reapotMlant at the premieoa bacauae: (check 1, 2 or '
1. |0^mployea ao IderV heiaolf;
2/Q Employee, waa perking work poradatent with being employed by the reepondent; or
3. □ other _____________ _ ____________ ;________
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Deacription of Individual. (Thia muat ba complatod tor all typea of aervloe exoept corportoa. Number III, above.) lu
Daponem deacribee the individual aarved aa toHowa: t-'LOr?»f 'I. -.re. hrftltrM *« JUm
dHVhHeSkin □ Black Hair □ 1«0 .□ Under 5' □ Undar 100 ba
□ Female □ Black Skin Hak tv □ 5'0^'3' - ‘.V 100-130 ‘
□ VMIowSkin Hair -'/ ' <• □i3i-ioc‘ i
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□ Brown Skin □ Gray Hair □ SMSA-vi □ OS'WO' '■ Y '' □181-^
□ Red Skin □ Red Hair ’ ‘'■ □ Over 86 _bO<er«'
□ White Half
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OthM IdMIMng characMt^
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Sworn Io boforo me on idA! ,1.. , niah ,
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* If not sworn, this statement shall constitute a cortifictes of service. •H
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