Appendix 6: Declaration Of Decontamination - Xylem Jabsco PUREFLO 21 Operation Manual

Appendix 6: Declaration of decontamination

Due to legal regulations for the protection of our employees and operating equipment, we require the
signed "Declaration of decontamination" before your order can be processed.
Company / Operator:
Contact person:
Optional information:
Type designation:
Submission reason:
Information
Did the product come into contact with medium?
Cleaning
Has the pump or the drive assembly been
cleaned properly and without residues?
Media details
What media did the product come into contact
with?
Has a safety data sheet been enclosed?
Hazard potential
Flammable Caustic
☐ ☐
The media/substances used react with:
Water
Air
Cleaner alkaline
Others
Date:
Jabsco
PUREFLO 21 Single Use
Innovative Systems GmbH
Irritant Explosive
☐ ☐
Name:
Email:
Phone:
Serial number:
☐YES
(Information on
☐YES
the medium is
omitted)
☐YES
Biohazardous Carcinogenic
☐ ☐
☐YES
☐YES
☐YES
☐YES
(name below)
Signature:
Operation Manual
(Cleaning and
☐NO information on
the medium are
omitted)
☐NO
☐NO
Toxic or very
Radioactive
toxic
☐
☐
☐NO
☐NO
☐NO
☐NO
XV