Teikoku USA | Chempump
Instruction Manual HE-10677-P (1018)
22
F. Decontamination Form
_
___________________________________________________________________________________________
____________________________________________________________________________________________
DECONTAMINATION CERTIFICATION
AND FLUSHING PROCEDURE
CUSTOMER
______________________________________
ADDRESS:
____________________________________
____________________________________
CONTACT:
____________________________________
DATE:
_______________________________
PHONE:
______________________________
EMAIL:
_______________________________
RMA #:
______________________________
Please complete the items below. By providing this information, you will allow us to work as quickly and safely as possible.
PUMP MODEL:
___________________________________
SERIAL NUMBER:
_______________________
:___________________________________
PART NUMBER
DATE INSTALLED:
_______________________
INDOOR / OUTDOOR:_
DATE PURCHASED:
_______________________________
___________________
REASON FOR RETURN:
WARRANTY REQUEST
FACTORY SERVICE
FAILURE INFORMATION:
Failure To Deliver Required Capacity
Vibration
Loses Prime After Starting
Bearing Failure
Motor Burnout
Other: ______________________
Bearing Monitor Reading
Axial Wear Due To Thrust
Insufficient Pressure
BRIEF DESCRIPTION OF PUMP FAILURE:
____________________________________________________________
DECONTAMINATION INFORMATION
All pumps/parts must be completely decontaminated and all information in this section must be completed prior to
shipment to our factory or service center. Shipments received without this documentation will not be accepted and
will be returned to the point of shipment.
CHECK ONE OF THE FOLLOWING:
Both the complete pump and the stator assembly have
been flushed by following the applicable steps in
section A, plus section B, C or D of the Teikoku USA
Flushing Procedure on pages 2 and 3 of this form. The
motor must be rewound.
FLUID PUMPED:
__________________________
WHAT FLUID DID YOU FLUSH WITH:
______________
DECONTAMINATION CERTIFIED BY: _____________________________
DATE:_______________________
Attach completed material safety data sheets (MSDS) for these fluids.
If either fluid is proprietary, please attach a
description of any characteristics that will assist
Teikoku USA
in safe handling. Without detailed and complete
information on the pumped fluid, we will not be able to process your order.
PROTECTION EQUIPMENT RECOMMENDED FOR SAFE HANDLING OF THE PROCESS FLUID: ____________
_____________________________________________________________________________
TITLE: ______________________________________________________ PHONE: _____________________
RETURN COMPLETED FORM AND PUMP/PART TO:
TEIKOKU USA
Sales and Service Center
5880 Bingle Road
Houston, TX 77092
Phone: (713) 983-9901
Fax: (713) 983-9919
TEIKOKU USA
Factory Service Center
959 Mearns Road
Warminster, PA 18974
Phone: (215) 343-6000
Fax: (267) 486-1037
TEIKOKU USA
Midwest Service Center
27881 State Route 7
Marietta, OH 45750
Phone: (740) 538-5332
Fax: (740) 538-5015
Pump is new/unused and never subjected to process fluid.
The pump has been flushed by following the applicable steps
in section A of the Teikoku USA Flushing Procedure on page 2
of this form. No liner rupture is suspected.
REV.
4-
17-20
