Fillable Asbestos Abatement 150 Des Moines Street Des Moines, (Office of the Chief Information Officer)

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Asbestos Abatement 150 Des Moines Street Des Moines, (Office of the Chief Information Officer)

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This form must be submitted with a contractor/supervisor or worker asbestos license application. Complete Part I and either Part
II or Part III. Send the original signed forms to the address above. A photocopy will not be accepted. The accuracy of this
document may be verified by the Iowa Division of Labor. Falsification of any part of this form may result in criminal charges,
denial of application, forfeiture of application fee, denial of future application and a civil penalty up to $5,000.00. Please print
legibly.
Part I
Iowa Division of Labor
Asbestos Abatement
150 Des Moines Street
Des Moines, IA 50309-1836
Phone: 515-281-6175
Fax: 515-725-2427
asbestos@iwd.iowa.gov
asbestos.iowa.gov
Applicant Information
Name
Date of birth
Phone number
Respirator Information
Respirator name
Respirator type
FOR OFFICE USE ONLY
Instructions
Date Received:
Asbestos License #:
Approved Denied
Fit Tester Information
Name
Company
Phone number
Address
City
State
Zip
Fit test method used
I certify that the above applicant has been successfully fit tested and is able to wear the above respirator. I certify that I am
familiar with the OSHA procedures for fit tests found in 29 CFR 1926.1101, Appendix C, and followed those procedures while
performing this fit test. I certify that the information on this form is true and accurate to the best of my knowledge.
Fit Tester Signature Date
200-002
03.28.2017
Part II
Part III
In order to protect my health, I will wear a positive pressure respirator such as a powered air purifying respirator whenever I am
in a regulated area.
Applicant Signature Date
Respiratory Protection Form
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Asbestos Abatement 150 Des Moines Street Des Moines, (Office of the Chief Information Officer)

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Completed 20 July 2020

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