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RESPIRATORY PROTECTION R-HS 13 VSD <br />Employee Sign-Ofd Sheet ASG 10 2005 <br />Res irato Protection <br />7 5µN JUNWUIN COUNTY <br />OFFICE OF EMERGENCY SERVICES <br />Name: LAR) fCS JU& K� MAU U CL__ Date: (- 2 S --0 5 <br />Last, First MI <br />A. Employee has received instruction on proper care of respirator. <br />B. Employee received detail review on donning of respirator. <br />C. Employee has received instruction on cleaning and storage of <br />Respirator. <br />D. Employee has demonstrated positive/negative respirator test. <br />E. Employee has completed respiratory questionaire and examination <br />F. Employee has been fit tested (See form FM 130.20) <br />I acknowledge receiving the training described in this document and I commit to abiding <br />by the safety rules and regulations presented to me. <br />J <br />2 December 2003 7 Sierra Chemical Co. <br />