श्रम आयुक्त 
(PRESCRIBED UNDER RULE 16)
RECORD OF LIME WASHING, PAINTING ETC.
| Part of factory e.g. name of room | Parts lime-washed, painted, varnished or oiled e.g. walls, ceiling, wood work etc. | Treatment, whether lime-washed, painted varnished or oiled | Date on which lime-washing, painting varnishing or oiling was carried out (according to the English calendar) | Remarks | ||
|---|---|---|---|---|---|---|
| Date | Month | Year | ||||
| 1 | 2 | 3 | 4 | 5 | 6 | 7 |