QUALITATIVE RESPIRATOR FIT TEST
This Respirator Fit Test is valid for the period of 12 (twelve) months from the data of test
Name
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Test Provider: ANDO INTERNATIONAL INC. Test Agent:
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Address: " 861 Manhattan Ave., Brooklyn, NY 11222 1. Irritant Smoke _d__
Telephone: (718) 349-6212 2. Odorous Vapor_
Far: (718) 349-3238 3. Taste Test —
1
RESPIRATORS TESTED - SUCCESSFUL TEST
/ (Half Face Mask only)
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BRAND NAME (l) V V (2) SIZE: (t) (2) ~—
~r E S T DATE
Name of person performing respirator fit test:
Fit test number O91 0 ('_01 Signature:,
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LI
NYC-WTC 000120535
OCR can misread numbers and units. Confirm readings against the page image before using them.
NYC-WTC_000120535Source: NYC Law Department, mirrored locally