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5amplot EMERGENCY EYEWASH AND SAFETY SHOWER INSPECTIONS CA.II�. <br /> 10k 1JWNj; l Ilii" a. � <br /> A. Eyewash and/or Shower Stations (i. e. plumbed units} <br /> Station Ili## Weekly Flow Test ( initial ) Accessible? Comments <br /> w; r • .r�" � Week 1 V� Weelr, 2 (Week 3 y �f J N <br /> Week c! Week 5 _ <br /> /� r4 . Ygnl� <br /> Week l �Z%Week24ZGWeek3 � <br /> Week 4 jerNeek 5 / N <br /> .v ► , Toin �l Week VWeek2I!L* Week3 voo� /;, / N <br /> Week 4 � Week 5 _ UU�� <br /> Week 1 _ Week 2 _ Week 3 _ Y / N <br /> Week 4 Week 5 <br /> Week 1 _ Week2 _ Week 3 _ Y / N <br /> Week4 _ Week <br /> B. Portable Eyewash Units (i. e. solution filled units or saline eyewash units) <br /> Filled with Caps/Seals Expiration <br /> Unit lD# Solution ? Intact? Accessible ? Date Comments/Deficiencies <br /> / N / NJN <br /> / NjN / N <br /> J <br /> Y / N Y / N Y N - <br /> Y / N Y / N Y / N —a Z <br /> Y / N Y / N Y / N <br /> niEcr- Adt �llz C lL'/ �/�. & sc3 17L4 I <br /> 9. <br /> Inspector' s Name Inspector's Signature Date -- <br /> Retail Facility Inspections Ver: 1 <br />