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SIMPI L EMERGENCY EYEWASH AND SAFETY SHOWER INSPECTIONS CJ1.R.E. <br /> A. Eyewash and/or Shower Stations (i. e. plumbed units) <br /> Station ID# Weekly Flow Test ( Initial ) Accessible ? Comments <br /> Week 1 '.Meek 2 Y' Week 3 _ <br /> r' Week 4 , 1 Week 5' <br /> Week 1 _ Week 2 Week 3 / N <br /> a/rn Week 4 Week 5 `� <br /> Week l _ Week 2 Week !Y / <br /> Week 4 = Week 5 Week 1 Week 2 Week3Week 4 Week 5 N <br /> Week 1 Week 2 Week 3 <br /> Week 4 _, Week 5 . Y / N <br /> _ t <br /> B. Portable Eyewash Units (i. e. solution filled units or saline eyewash units) <br /> Unit IN Solution ? <br /> with Caps/Seals Expiration <br /> Solution ? Intact? Accessible . Date Comments/Deficiencies <br /> 7,hop lJG'/ N / N YI'/ N <br /> 1110 <br /> N PIT <br /> r ? 1� fL✓^ < 3 > <br /> Y / N Y / N Y / N , <br /> Y / N Y / N Y / N <br /> Y / N Y / N Y / N17 <br /> ro 40 <br /> Inspector's Name Inspector's Signature Date ! <br /> Retail Facility Inspections <br /> Ver. 1 <br /> EMERGENCY <br />