Watson-Marlow PD/40 - Manual (Page 23)

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10 SAFETY FORM
Product Use and Decontamination Declaration
In compliance with Health & Safety Regulations the user is required to declare the substances which have been in contact
with the product(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 ensure that we have
the information before receipt of the item(s) being returned. A further copy must be attached to the outside of the packaging
containing the item(s). The user is responsible 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: ……………..…………………………………………………………………………………..…………
Zip Code: ...……………………………….……
Town: …….…………………………………
Country: ………….……………………………
Telephone: ………………..…………………………………
Fax: ..………………………………………………...
2. Product: …………………………………….… 3.4 Cleaning fluid to be used if residue of chemical is found
during service:
(a) ……………………………………………….…
(b) ……………………………………………….…
(c) …………………………………………….……
(d) …………………………………….……….…
2.1 Serial Number:…………………………………….
2.2 Has the Product been used?
Yes (Go to section 3)
No (Go to section 4)
3. Details of the substances pumped
4. I hereby confirm that the only substance(s) that the
equipment specified has pumped or come into contact
with those named, that the information given is correct
and the carrier has been informed if the consignment is
of a hazardous nature
3.1 Chemicals names:
(a) ………………………………..……..……….
(b) ……………………………….……………….
(c) …………………………………….…....……
(d) ..…………………………………...………….
5. Signed: ……………………………..……………
Name: …………………..……...……………….
Position: ………………………………..…………
Date: ……………………………….………….
3.2 Precautions before handling these substances:
(a) ………………………………………………..
(b) …………………………………………….….
(c) ………………………………………………..
(d) ………………………………………………..
Note: To assist us in our service, please describe any
fault condition you have witnessed.
……………………………………………………………
……………………………………………………………
……………………………………………………………
……………………………………………………………
……………………………………………………………
3.3 Actions to be taken in event of human contact:
(a) ………………………………………………..
(b) …………………………………………….….
(c) ………………………………………………..
(d) ………………………………………………..