B
DEVICE PERIODIC CHECK SHEET.
No.
(O) Date.
1
2
3
4
5
6
7
8
9
10
(P) Reason for check.
O
Periodic check.
O
Additional check.
O
Periodic check.
O
Additional check.
O
Periodic check.
O
Additional check.
O
Periodic check.
O
Additional check.
O
Periodic check.
O
Additional check.
O
Periodic check.
O
Additional check.
O
Periodic check.
O
Additional check.
O
Periodic check.
O
Additional check.
O
Periodic check.
O
Additional check.
O
Periodic check.
O
Additional check.
(Q) Name and signature of the person
responsible for checking.
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