Eyewash Station - Annual Inspection Form - Keyes printable pdf download

Eyewash Station - Annual Inspection Form - Keyes

Eyewash Station – Annual Inspection

Name of Property: ________________________________________Date: ______________________

Location of Eyewash Station: _______________________________ Model: _____________________

Name of Technician: _________________________________________________________________

Affiliation of Technician: ______________________________________________________________

Signature of Technician: ______________________________________________________________

Evaluate each eyewash station for compliance with the following requirements:

Pass

Fail

N/A

Comments

1. Eyewash station is located within 10-seconds

(55-feet) of hazard

2. Eyewash station is located so there is no door

between the hazard and the eyewash that is

lockable and does not swing in the direction of

the eyewash where the hazard is not corrosive

3. Eyewash station is well-lit and designated by a

highly visible sign

4. Eyewash station is on same level as hazard

and access to eyewash is not obstructed

5. Flow of water begins in 1-second or less

6. Water valve remans open with hands-free

operation

7. Eye/face wash outlets are protected from

contaminants with covers

8. Minimum water flow of 0.4 gpm for eyewash,

and 3.0 gpm for eye/face wash for 15-minutes

9. Flushing fluid to both eyes simultaneously at a

minimum of 4-inches in length and less than 8-

inches above the nozzle

10. The height of the flushing fluid is 33-inches to

53-inches above the floor

11. The flushing fluid must be a minimum of 6-

inches from wall or other obstructions

12. Flushing fluid must be tepid (60° F to 100° F)

All “Failed” issues must be repaired and re-tested.

Source: ANSI Z358.1-2014

Supervisor’s Initial: _________ Date: __________________ Work Order #: _______________________

Eyewash Station - Annual Inspection Form - Keyes