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APPENDIX #4: Therm-O-Mix WWM Safety Shower Station Checklist
Run #1
Run #2
Company_________________________________
Plant Location_____________________________
Serviceman/Company_______________________
Station/Serial Number_______________________
Contact___________________________________
Phone____________________________________
Date_____________________________________
Unit Location______________________________
Eyewash Temperature:_________________ F / C
Shower Temperature:__________________ F / C
Eyewash Start-up Spike:________________ F / C
Shower Start-up Spike:_________________ F / C
Eyewash Temperature:_________________ F / C
Shower Temperature:__________________ F / C
Eyewash Start-up Spike:________________ F / C
Shower Start-up Spike:_________________ F / C
Does the plant have adequate hot water flow pressure? (Recommended min. 45 PSIG/
max. 100 PSIG________________
Is the stations hot water supply line properly sized? (Recommended min. 1” IPS)_______________
Does the plant have adequate cold water flow pressure? (Recommended min. 45 PSIG/
max. 100 PSIG________________
Is the stations cold water supply line properly sized? (Recommended min. 1” IPS)______________
Is the station supplying tempered water to anything other than the Safety Shower Station?
YES/NO
If “YES,” explain:__________________________________________________________________________
__________________________________________________________________________________________
Are freeze and scald protection valves installed correctly? YES/NO
If “NO,” please explain:____________________________________________________________________
__________________________________________________________________________________________
Is the cold water supply line or the tempered water outlet in contact with or being overheated
by another source? (Steam supply lines, steam tracing or solar radiation) YES/NO
If “YES,” please explain:___________________________________________________________________
__________________________________________________________________________________________
Comments
:_______________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________