Title Page
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Conducted on
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Prepared by
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Location
PERSONNEL DETAILS
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Employer
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Employee
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Date Mask Was Issued
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RPE Identification Number
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Make and Model of RPE
INSPECTION DETAILS
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Date and time of inspection
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Harness
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Valves & Seals
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Body of the mask
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Cleanliness & Condition of mask
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Filters in date / good condition
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Being stored correctly?
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Additonal Comments Actions
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Fit for use?
PERSON COMPLETING INSPECTION
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Add signature
