Grundfos MTA 110H-180 Installation And Operating Instructions Manual Download Page 9

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Appendix

Certificate of cleanliness

Please provide all pertinent information

Product Description

Product Number

Quantity

The r

The ref

efer

erenced pr

enced pr

enced produc

oduc

oducttttt has been e

has been e

has been exposed to to

xposed to to

xposed to toxic or haz

xic or haz

xic or hazar

ardous ma

dous ma

dous materials:

terials:

YYYYYES NO

ES NO

If y

If yes

es, c

, c

, complete SECT

omplete SECT

omplete SECTION A. If no

ION A. If no

ION A. If no, c

, c

, con

ontinue to SECT

tinue to SECT

tinue to SECTION B

ION B

ION B.....

APPLICATION

PPPPPlease specif

lease specif

lease specify all haz

y all haz

y all hazar

ardous ma

dous ma

dous materials/

terials/

terials/substances used with the r

substances used with the r

substances used with the ref

efer

erenced pr

enced pr

enced produc

oduc

oduct(s

t(s

t(s).

).).

PPPPPrrrrrooooovide the Ma

vide the Ma

vide the Material Saf

terial Saf

terial Safety Da

ety Da

ety Data Sheet

ta Sheet

ta Sheet f

for all ma

or all ma

or all materials r

terials r

terials ref

efer

erenced or list

enced or list

enced or list pr

precautions to be tak

ecautions to be tak

ecautions to be taken when handling these

en when handling these

substances. Also

substances. Also, pr

, pr

, prooooovide an

vide an

vide any ac

y ac

y actions to be tak

tions to be tak

tions to be taken in the e

en in the e

en in the evvvvven

enttttt of human c

of human c

of human con

ontac

tac

tacttttt with an

with an

with any liquid within the pr

y liquid within the pr

y liquid within the produc

oduc

oducttttt (e

(evvvvven

after cleaning and/

ter cleaning and/

ter cleaning and/or flushing).

or flushing).

The pr

The produc

oduc

oducttttt r

returned has been dec

eturned has been dec

eturned has been decon

ontamina

tamina

taminated, dr

ted, dr

ted, drained of liquid and is saf

ained of liquid and is saf

ained of liquid and is safe to handle

e to handle

e to handle. P

. P

. Prrrrrooooovide dec

vide dec

vide decon

ontamina

tamina

tamination method

tion method

used.

ECTION

A: T

OXIC

LEARANCE

(To be completed if applied substances are hazardous)

Initial/Da

Initial/Date

The pr

The produc

oduc

oducttttt r

returned has not

eturned has not

eturned has not handled or been in c

handled or been in c

handled or been in con

ontac

tac

tacttttt with an

with an

with any to

y to

y toxic or haz

xic or haz

xic or hazar

ardous substances.

dous substances.

dous substances. The pr

The pr

The produc

oduc

oducttttt has been

has been

drained of liquid and is saf

ained of liquid and is saf

ained of liquid and is safe to handle

e to handle

e to handle.....

ECTION

B: N

-T

OXIC

LEARANCE

(To be completed if applied substances ar

are not

e not

e not hazardous)

Initial/Da

Initial/Date

I her

I hereby declar

eby declar

eby declare tha

e tha

e thattttt the c

the c

the con

onten

ten

tents of this c

ts of this c

ts of this consignmen

onsignmen

onsignmenttttt ar

are fully and accur

e fully and accur

e fully and accuraaaaately described abo

tely described abo

tely described abovvvvve by pr

e by pr

e by proper shipping name and ar

oper shipping name and ar

oper shipping name and areeeee

classified, pack

classified, packed, mark

ed, mark

ed, marked and labeled, and ar

ed and labeled, and ar

ed and labeled, and are in all r

e in all r

e in all respec

espec

espects in pr

ts in pr

ts in proper c

oper c

oper condition f

ondition f

ondition for tr

or tr

or transpor

anspor

ansport, by all modes

t, by all modes

t, by all modes, acc

, acc

, accor

ording to applicable

ding to applicable

interna

terna

ternational and na

tional and na

tional and national go

tional go

tional govvvvvernmen

ernmen

ernmental r

tal r

tal regula

egula

egulations. Health and saf

tions. Health and saf

tions. Health and safety issues ar

ety issues ar

ety issues are clearly understood and will be giv

e clearly understood and will be giv

e clearly understood and will be given

ccccconsider

onsider

onsideraaaaation during shipmen

tion during shipmen

tion during shipmenttttt. (A r

. (A r

. (A repair or inspec

epair or inspec

epair or inspection of pr

tion of pr

tion of produc

oduc

oducttttt will only be under

will only be under

will only be undertak

tak

taken when this cer

en when this cer

en when this certifica

tifica

tificate has been c

te has been c

te has been completed

ompleted

and authoriz

and authorized by a qualified member of staf

ed by a qualified member of staf

ed by a qualified member of staff emplo

f emplo

f employyyyyed by the r

ed by the r

ed by the returning c

eturning c

eturning compan

ompan

ompanyyyyy.)

.).)

RRadioac

adioac

adioactiv

tiv

tive pr

e pr

e produc

oduc

oducts will not

ts will not

ts will not be accepted f

be accepted f

be accepted for r

or r

or repair

epair

epair.....

A return material authorization number from Grundfos, along with a completed and signed copy of

this form must accompany the returned product. It is the senders responsibility to package, transport and complete the shipping documents regarding the
nature of the product shipped. Irrespective of this, Grundfos reserves the right to reject the service order for other reasons. Grundfos will rely on this
representation and will look to the customer for reimbursement of any and all costs, claims or damages incurred, including attorney’s fees, if any representation
is not correct.

CCO

OMP

MPAN

ANYYYYY

NAME