UNCONVENTIONAL RESOURCES MAINTAIN POTENTIAL PROJET (URMPP)

CONTRACT NO. 660005091

NA Gas Production 2 Wells
EYE WASH INSPECTION CHECKLIST
An eyewash station can be a life-saving device, especially in the manufacturing industry, if a
worker is exposed to harmful chemicals or other substances. By quickly flushing the eyes
with water, it can help to remove the substance and prevent serious injury.

Month & Year Facility/Site Name Location: Eye Wash No.:

O
No. Item No Comments
k
1 Tank handle on the top to allow for easy handling is in good condition
2 Is there any hole that allows water to leak
3 A wide fill opening with threaded cap permits easy inspection, cleaning, and filling
4 The fold-down eyewash arm has a positive upper limit stop that also covers and
protects the spray outlets when not in use.
5 Are the jets or spray outlet working properly
6 Water is clean and tank replenish as per schedule
7 Is the area around the station clear of obstruction

DAILY & WEEKLY INSPECTION

W# S M T W T F S Date Refill Name/Signature
1 1 2 3 4 5 6 7
Ok
No

W# S M T W T F S Date Refill Name/Signature

2 8 9 10 11 12 13 14
Ok
No

W# S M T W T F S Date Refill Name/Signature

3 15 16 17 18 19 20 21
Ok
No

W# S M T W T F S Date Refill Name/Signature

4 22 23 24 25 26 27 28
Ok
No

W# S M T W T F S Date Refill Name/Signature

5 29 30 31
Ok
No

Note: Water contents shall be replaced immediately after use or when the water level is less than the
required capacity of the tank.