Watson Marlow Pumps 501 Trio Manual page 11

Product use and decontamination declaration
In compliance with the UK Health & Safety at Work Act and the Control of Substances Hazardous to Health
Regulations you, the user are required to declare the substances which have been in contact with the product(s)
you are returning to Watson-Marlow or any of its subsidiaries or distributors. Failure to do so will cause delays in
servicing the product. Therefore, please complete this form to ensure that we have the information before receipt
of the product(s) being returned. A FURTHER COPY MUST BE ATTACHED TO THE OUTSIDE OF THE PACKAG-
ING CONTAINING THE PRODUCT(S). You, the user, are responsible for cleaning and decontaminating the
product(s) before returning them.
Please complete a separate Decontamination Certificate for each pump returned.
RGA 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
Sections
If no, please complete Section
5 only
3 Details of substances pumped
3.1 Chemical names:
(a) ....................................................... 5 Signed ........................................................ ...........
(b) .......................................................
(c) .......................................................
(d) .......................................................
3.2 Precautions to be taken in
handling these substances:
(a) ........................................................
(b) .......................................................................................................
(c) ........................................................
(d) ........................................................
3.3 Action to be taken in the event of human contact:
(a) ............................................................................
(b) ............................................................................
(c) ............................................................................
(d) ............................................................................
Watson-Marlow Limited Falmouth Cornwall TR11 4RU England Tel: 01326 370370 Fax: 01326 376009
3.4 Cleaning fluid to be used if residue of chemical is found during
servicing;
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.
Name .........................................................
Position .......................................................
Date ...........................................................
11
Postcode ........................................
Fax Number ....................................
(a)
(b) ...................................................
(c) ...................................................
(d) ...................................................
Note: To assist us in our servicing
please describe any fault condition you
have witnessed.