NYC 9/11 Public Portal Document
ErmaowMrNV3 pRortct►ON ' .:.
TH& Cn or NW Yoai - baAamD4 of ROBERT C.'AVALTRONI
JOEL A. M)ELE, Sit., P.E. omIukàer
ti Deputy Commissioner
8ureau-of
.vE (718) Air, Noise, & Hazardous
Materials
APPLICATION FOR ASBESTOS INVESTIGATOR
CERTIFICATION
AND RESTRICTED ASBESTOS INVESTIGATOR
APPLICANT NAME:
A
HOME ADDRESS: _
cITY, STATE, &ZIP. _
TELEPHONE NUMBER:
DATE OF BIRTH:
SOCIAL SECURITY NO
P11
`.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-----.-
-.-.---APPLI 'S SIGNATURE
t y
BASED UPON THE MEDICAL EXAMINATION WHICH INCLUDED
PULMONARY •FUNCTION TESTS. OF VITAL CAPACITY (FVC)
AND FORCED EXPIRATORY VOLUME AT ONE SECOND
(FEV1). AND AWEVALUATION OF A RECENT CHEST
ROENTGENOGRAM, IT IS MY OPINION THAT.THE ABOVE
NAMED PATIENT IPLF„AS$C ECKfJ) ApPROPRIATEBOX)
IS Q IS NOT
PHYSI AL.I. QUALIFIED TO WEAR A RESPIRATOR IN THE
PERFORMANCE OF HIS/HER JOB.
HEIGHT: r 11
TOBACCO: ~~ -_SEIZURES,7EPILEPSY t~ ACROPHOBIA: r
_
i X-RAY CHEST: N ` PFR`: ~ 1 --
01/25/01
MARK I. KAMINSKI D
PRINT NAME OF P DATE OF EXAMINATION
S1 P CIAN • MEDICAL/ PRL°IAL OFFICES
194 NASSAU AVE. &I CKLYN, N.Y. 11222
N.Y. STATE LIC.NO: 212208 Tr+ g~p
719) I Q ti77r, !V (7te) 3! -7154—
STATE LICENSE NUMBER TELEPHONE NUMBER
NYC-WTC 000094987
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