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TOTAL CHLORINE: WATER CHECKLIST
FACILTY_____________________________________ MONTH/YEAR__________________= ______
DATE              
METE= R USED              
   
FIRST SHIFT Monday Tuesday Wednesday Thursday Friday Saturday Sunday
Time AM/PM              
Tot= al Chlorine (<0.1 mg= /L)              
Primary Tank              
Tot= al Chlorine (<0.1 mg= /L)              
Secondary Tank (if = appl.)              
Per= son Performing Test              
Lic= ensed Staff Initials              
SECOND SHIFT              
Time AM/PM              
Tot= al Chlorine (<0.1 mg= /L)              
Primary Tank              
Tot= al Chlorine (<0.1 mg= /L)              
Secondary Tank (if = appl.)              
Per= son Performing Test              
Lic= ensed Staff Initials              
THIRD SHIFT              
Time AM/PM              
Tot= al Chlorine (<0.1 mg= /L)              
Primary Tank              
Tot= al Chlorine (<0.1 mg= /L)              
Secondary Tank (if = appl.)              
Per= son Performing Test              
Lic= ensed Staff Initials              
FOURTH SHIFT              
Time AM/PM              
Tot= al Chlorine (<0.1 mg= /L)              
Primary Tank              
Tot= al Chlorine (<0.1 mg= /L)              
Secondary Tank (if = appl.)              
Per= son Performing Test              
Lic= ensed Staff Initials              
NOTE: File completed form in facility's Water/Technical Master= File.
This document is the proprietary property of Renal Advantage, Inc. and may not= be reproduced without written permission.
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