DP
CITY OF NEW YORK
DEPARTMENT OF ENVIRONMENTAL PROTECTION
1UREJ.0 OF
aJV TAL (AnONANT) eaDRCD.4
ASBESTOS CONfRat.PR AM • T7AA14C AND CERTUICA floM U1'-.T
EP17 JUNCfONDCXAEVAI D.11H n.oOR. CI*DNA.?..w YORK I L%u
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APPLICATION FOR ASBESTOS INVESTIGATOR
AND RESTRICTED ASBESTOS INVESTIGATOR CERTIFICATION
APPENDIX A
MEDICAL EXAMINATION FOR ASBESTOS INVESTIGATORS
APPLICANT NAME-i
HOME ADDRESS:
CITY, STATE. & ZIP;
TELEPHONE NUMB
DATE OF BIRTH: E
SOCIAL SECURITY;
BASED UPON THE MEDICAL EXAMINATION WHICH INCLUDED
PULMONARY FUNCTION TESTS OF VITAL CAPACITY (FVC)
AND FORCED EXPIRATORY VOLUME AT ONE SECOND
(FEV1), AND AN EVALUATION OF A RECENT CHEST
ROENTGENOGRAM, IT IS MY OPINION THAT THE ABOVE
NAMED PAT!ENT !PLEASE CHECK APPROFRif;TE SGX)
ai
IS
I
0 IS NOT
PHYSICILY QUALIFIED TO WEAR A ES
RESPIRATOR IN THE
PERFORMANCE OF HIS/HER JOB.
•
Pil
NYC-WTC 000120532
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NYC-WTC_000120532Source: NYC Law Department, mirrored locally