Safety Form - Bredel Hose pump Series Manual

SAFETY FORM

Safety form
Product Use and Decontamination Declaration
In compliance with the Health and Safety Regulations, the user is required to declare those substances that
have been in contact with the item(s) you are returning to Watson-Marlow Bredel B.V. or any of its subsidiaries or
distributors. Failure to do so will cause delays in servicing the item or in issuing a response. Therefore, please
complete this form to make sure we have the information before receipt of the item(s) being returned. A com-
pleted copy must be attached to the outside of the packaging containing the item(s). You, the user, are respon-
sible for cleaning and decontaminating the item(s) before returning them.
Please complete a separate Decontamination Certificate for each item returned. RGA/KBR no...................
1 Company ............................................................. .........................................................................................
Address ................................................................ .........................................................................................
Telephone .............................................................
2 Product ................................................................
2.1 Serial Number ......................................................
2.2 Has the Product been used?
YES NO
If yes, please complete all the following para-
graphs.
If no, please complete paragraph 5 only
3 Details of substances pumped
3.1 Chemical Names
a) ..........................................................................
b) ..........................................................................
c) ..........................................................................
d) ..........................................................................
3.2 Precautions to be taken in handling these sub-
stances:
a) ..........................................................................
b) ..........................................................................
c) ..........................................................................
d) ..........................................................................
3.3 Action to be taken in the event of human contact:
a) .........................................................................
b) .........................................................................
c) .........................................................................
d) .........................................................................
Postal code...........................................................
Fax number ..........................................................
3.4 Cleaning fluid to be used if residue of chemical is
found during servicing;
a) ........................................................................
b) ........................................................................
c) ........................................................................
d) ........................................................................
4 I hereby confirm that the only substances(s) that
the equipment specified has pumped or come into
contact with are those named, that the information
given is correct, and the carrier has been informed
if the consignment is of a hazardous nature.
5 Signed .................................................................
Name ...................................................................
Position ................................................................
Date .....................................................................
Note:
To assist us in our servicing please describe
any fault condition you have witnessed.
.............................................................................
.............................................................................
.............................................................................
.............................................................................
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SAFETY FORM