Watson-Marlow 101F - Manual (Page 14)

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 us er are required to dec lare the s ubstances which have been in c ontact with the pr oduct(s)
you are returning to W atson-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 pr oduct(s) being r eturned. A FURTHER COPY
MUST
BE ATTACHED TO THE OUTSIDE OF THE
PACKAGING 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
................................................... Postcode ………………………………………
Telephone ................................................ Fax Number …………………………………..
2 Product
3.4 Cleaning fluid to be used if residue of chemical is found during
servicing;
2.1 Serial Number .......................................
(a)………………………………………………….
2.2 Has the Product been used? (b)…………………………………………………
YES NO
(c)…………………………………………………
(d)…………………………………………………
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)……………… ...........................
(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 …………………………………………………..
3.2 Precautions to be taken in handling these substances:
(a)………… ........................................................
(b)………… ....................................................... ……………
Note: To assist us in our servicing
(c) ……………… .................................................. please describe any fault condition you
(d)………………. ..................................................
have witnessed.
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