ALP
since 1928
ALP
since 1928
31
11 / SECURITY FORM
In compliance with Health & Safety Regulations you, the user are required to declare the substances that
have been in contact with the product(s) you are returning to ALBIN PUMP S.A.S. 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).
You, the user, are responsible for cleaning and decontaminating the item(s) before returning them.
Please complete a separate decontamination certificate for each item returned.
• 1.0 /
COMPAGNY NAME
Address
City
Postal code
Country
Téléphone
Fax number
• 2.0 / PUMP
2.1 / SERIAL NUMBER
2.2 / Has the pump been used ?
YES NO
If yes, please complete all the following paragraphs. If no, please complete paragraph 5 only.
• 3.0 / DETAILS of substances pumped
3.1 / CHEMICAL Names
a)
b)
c)
3.2 / Precautions to be taken in handling these substances
a)
b)
c)
3.3 / Action to be taken in the event of human contact
a)
b)
c)
3.4/ Cleaning fluid to be used if residue of chemical is found during servicing.
• 4.0 /
“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.”
• 5.0 /
Signed
Name
Position
Date
Remarks : to assist us in our servicing please describe any fault condition you have witnessed.
ALP Instruction Manual -2011EE-GB.indd 31
21/07/11 20:49
