NYC 9/11 Public Portal Document
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50-17 JUNCTION BOULEVARD, STH FLOOR, CORONA, NEW YORK tes
yg CITY OF NEW YORK
D DEPARTMENT OF ENVIRONMENTAL PROTECTION
| BUREAU OF ENVIRONMENTAL REMEDLATION AND ENFORCEMENT
- ASBESTOS CONTROL PROGRAM - TRAINING AND CERTIFICATION Upon
APPLICATION FOR ASBESTOS INVESTIGATOR
AND RESTRICTED ASBESTOS INVESTIGATOR CERTIFICATION
i APPENDIX A
MEDICAL EXAMINATION FOR ASBESTOS INVESTIGATORS
| ;
APPLICANT NAME
HOME ADDRESS:
CITY, STATE, & ZIF
TELEPHONE NUM
DATE OF BIRTH: _
Pil
SOCIAL SECURITY:
BASED UPON THE MEDICAL EXAMINATION WHICH INCLUDED
PULMONARY FUNCTION TESTS OF VITAL CAPACITY (FVC)
AND FORCED EXPIRATORY VOLUME AT ONE SECOND
(FEV,), AND AN EVALUATION OF A RECENT CHEST
ROENTGENOGRANM, IT IS M'f OPINION THAT THE ABOVE
NAMED PATIENT (PLEASE CHECK (!) APPROPRIATE BOX)
= IS 0 IS NOT
PHYSICALLY QUALIFIED TO WEAR A RESPIRATOR IN THE
PERFORMANCE OF HIS/HER JOB.
NYC-WTC_000120499
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NYC-WTC_000120499Source: NYC Law Department, mirrored locally