Eye Wash Station Inspection

• Document No.

• Conducted on

  Date

Portable Eye Wash Station #1 (Facilities Cage)

• Is the eye wash station reservoir filled at least half way with eye washing solution?

  Yes

  No

  N/A

• Does the eye wash station operate as intended.

  Yes

  No

  N/A

• Is the eye wash station free of physical damage and does not leak?

  Yes

  No

  N/A

• Have the Float Covers been securely fastened?

  Yes

  No

  N/A

Portable Eye Wash Station #2 (Zip Digital)

• Is the eye wash station reservoir filled at least half way with eye washing solution?

  Yes

  No

  N/A

• Does the eye wash station operate as intended.

  Yes

  No

  N/A

• Is the eye wash station free of physical damage and does not leak?

  Yes

  No

  N/A

• Have the Float Covers been securely fastened?

  Yes

  No

  N/A

Plumed Eye Wash Station #3 (Back Warehouse)

• Does the eye wash station operate as intended.

  Yes

  No

  N/A

• Does the shower operate as intended.

  Yes

  No

  N/A

Inspection Completion

• Based on the performed inspection are the Eye Wash Stations working as intended? (Please document or photograph any visible damage)

  Safe

  At Risk

  N/A

• Eye Wash Station Inspection Was Completed On:

  Date

• Please sign in the space provided to verify that the above responses are accurate to the best of your knowledge.

  Sign