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SimEMERGENCY EYEWASH AND SAFETY SHOWER INSPECTIONS <br /> A. Eyewash and/or Shower Stations (i.e. plumbed units) <br /> Station ID# Weekly Flow Test(Initial) Accessible? Comments <br /> C"A" Week 1 j Week 2% Wee'<3 V <br /> %VLek 4f Week 5_ ; N <br /> Week 1 _ Week 2V1 Week3 _ j <br /> Week 4 J Week S— -N — —- — - - - -- <br /> e Week 1 T Week 2 Week3� i <br /> Week 4 N1 Week 5 N <br /> �Y Week 1 Week 2 Week3 Y/ N — -- — - — <br /> Week 4_ Week 5_ � <br /> Week!_ Week 2_ Week3 -�— <br /> Week 4 Week 5 Y/ N <br /> B. Portable Eyewash Units (i.e. solution filled units or saline eyewash units) <br /> ! Filled with Caps/Seals Expiration <br /> Unit ID# ? Accessible? Comments/Deficiencies <br /> Solution. I tact. Date <br /> e Y/ N Y N Y N <br /> 1 /- /- <br /> N N Y N <br /> f- � • 2ul� tTl <br /> 9N Y N , Y N c <br /> Y Y/N Y/ N rn Z o <br /> �; <br /> Y/N-� —Y/ N Y - - a) M <br /> j Z op <br /> - -Y// N Y Y -- rn Z r C3 <br /> --1-- <br /> �/�` <br /> Inspector's Name Inspector's Signature Date Z <br /> Retail Facility Inspections Ver.1 <br />