Laserfiche WebLink
V91191ZVV9 Id.dd rAA ILK1S F1LLU SLHVIULS IjEO14/014 <br /> i WEIVED <br /> TERIS FIELD SERVICES APR 14 2005 <br /> RESPIRATOR FIT TEST RECORD SAN JOAQUIN COUNTY <br /> OFFICE OF EMERGENCY SERVICES <br /> Employee: _ David Williamson Date2/07/03 <br /> Social Security Number: Office: Benicia,Ca <br /> Respirator Type: Dual Cartridge, Full Face Respirator ID(#, Initials, etc): RP25/RP26 <br /> Manufacturer, Wilson Model/Size: Laroe <br /> Tests: ® Negative Pressure Check Irritant Smoke Qualitative Test <br /> Positive Pressure Check Isoamys Acetate Qualitative Test <br /> ❑ Other: <br /> Normal Breathing: Y-45 _ <br /> Deep Breathing: yr" <br /> Side-To-Side/tlp-And-Down Head Movements: <br /> Talking: <br /> Other Exercises (as appropriate): Y05 <br /> Employee briefed on fundamental principles for respiratory protection, use, inspection, deaning, maintenance, <br /> and storage of equipment: � A_*' Yes No <br /> Corrective len_es required for normal work tasks: _Z—Yes No <br /> If yes, which does employee use? -9-prescription safety glasses <br /> ,,// prescription safety goggles <br /> ti respirator spectacles <br /> Facial characteristics preventing seal <br /> (beard, missing dentures, etc.): Yes ,r <br /> Medical restrictions on respirator use: Yes o_No <br /> I hereby certiF/ that the subject employee has been fit tested according to the procedure specified in 29 CFR <br /> 1910.120. The results of the test(s) indicated the subject employee is accepted (_Z)/rejected( )for <br /> work assignments requiring specified respiratory protection devices. <br /> David Williamson 2/7/03 <br /> Employee (Print Name) (Signature) (Date) <br /> Phet Sinthavong 2/7/03 <br /> Safety&Health Mgr. (Print Name) ate (Date) <br /> F-0859;Rev:2 -Trxis Field Service Respirator Fit Test Record <br /> 05/01/07 <br />