Attachment 3 Workstation 3.doc

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Professional Engineer for Dust Collector
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N4215822QA001
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Text version

VENTILATION SURVEY FORM

COMMAND/SHOP INFO
INSTRUMENT DATA

COMMAND:________________________________

SHOP:_____________________________________

DATE:_____________________________________

LOCATION:________________________________

VENTILATION TYPE:________________________

PROBE TYPE:________________________________

TYPE USED:_________________________________

RANGE:_________________________________FPM

SERIAL NUMBER:____________________________

CALIBRATION DATE:_________________________

DIAGRAM OF SYSTEM AND VENTILATION DATA:

Baseline (Year: )

ACGIH Recommendations

Last Year’s Reading

Continuous Flow Indicator Present?
Y or N (If Yes – type: )

Reading: (Acceptable reading: )

Vent Used For

Vent Acceptable?
Y or N

Based on: ACGIH; Low samples at these flowrates;

Other:

COMMENTS: Manometer: Off _______ On________ *Measurements taken at the intersection of the dashed lines

INDUSTRIAL HYGIENIST

69”

Workstation #3

(FPM)

12” _______

20” _______

24” _______

36” _______

48” _______

60” _______

72” _______

84” _______

96” _______

104” _______

LEFT

(FPM)

12” _______

20” _______

24” _______

36” _______

48” _______

60” _______

72” _______

84” _______

96” _______

104” _______

RIGHT

114 ½ ”

RIGHT 10” (in-line)

A=

Q=

LEFT 10” (in-line)

A=

Q=

15”

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