Watson-Marlow 5O5XY Robot - Manual (Page 28)

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
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) ......................................................
3.2 Precautions to be taken in
handling these substances:
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 …………………………………………………..
(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
28