Accomplishment:

1. Number 1 : Type of Eyewash and Safety Shower. Tick ( √ ) as applicable.

2. Number 2 : Number of Eyewash and Safety Shower
3. Number 3 : Location of Eyewash and Safety Shower
4. Number 4 : The last refill date of Eyewash and Safety Shower
5. Number 5 : The next refill date of Eyewash and Safety Shower
6. Number 6 : The date of performing of inspection.
7. Number 7 : The condition of shower valve. Filled with ‘good or broken”.
8. Number 8 : The condition of flushing fluid. Filled with “good or broken”.
9. Number 9 : The condition of Drainage. Filled with “good or broken”.
10. The condition whether any obstruction or not. Fill with NO or
Number 10 :
YES
11. The Condition of water inside tank (if the type is portable
Number 11 :
gallon)
12. Number 12 : ID number and signature of inspected personnel.
13. Number 13 : Additional remark if any.