Safety form, Product use and decontamination declaration, Safety form 80 safety form – Watson-Marlow SP40 User Manual

Page 83

SAFETY FORM

SAFETY FORM

Product Use and Decontamination Declaration

In compliance with the Health & 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 dis-
tributors. 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 no............................

Company ........................................................................................................................................................

Address ..........................................................................................................................................................

Telephone..............................................................

Postal code ...........................................................

Fax number ..........................................................

Product .................................................................

3.4 Cleaning fluid to be used if residue of chemical is

found during servicing;

a) ........................................................................

b) ........................................................................

c) .........................................................................

d) ........................................................................

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

Details of substances pumped

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.

3.1 Chemical Names

a) ..........................................................................

b) ..........................................................................

c) ..........................................................................

d) ..........................................................................

Signed .................................................................

Name ...................................................................

Position ................................................................

Date .....................................................................

3.2 Precautions to be taken in handling these sub-

stances:

a) ..........................................................................

b) ..........................................................................

c) ..........................................................................

d) ..........................................................................

Note:

To assist us in our servicing please describe
any fault condition you have witnessed.

..............................................................................

3.3 Action to be taken in the event of human contact:

a) .........................................................................

b) .........................................................................

c) .........................................................................

d) .........................................................................

This manual is related to the following products:

SP50