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EYE Wash Station Inspection

Month :

Sr. No. Check Point

Week 1 Week 2 Week 3 Week 4

1 Availability of Water

Water flow
2
(Ring / Circle Completed)

3 Cleaning

4 Dust

5 Leakages

6 Operation of Handle

7 Water Drain Line Clear

8 Sinages / Labels

9 Operating Instructions

10 Area free from material

Sign of Operator

Sign of Supervisor

Observations/ Commets

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