Document oD019MxDN65oRO75wED6rGzjX

Same: 1C1 BRAKE REPAIR AND MAINTENANCE WORKERS SURVEY Date: So. __________ Union Local Si Address: ____________ __________________________________________________ ' Street City State ZXP Telephone: ' Date of Birth:`Ago ____________________________ Sex ____ Garage Facility: Same of Physician (optional) ____________________._______________ Adaress: ____________________________ URINE: Albumin Protein SNYIHGNMSNTAL SCIBKCHiB. LABQ! CV A m.t-xT-vTY Y. v_- MOUNT SINAI SCHOOL OF MEDICINE OF THE CITY UNIVERSITY OF NEW YORK jm.*.