17
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 ....................................
3.4 Cleaning fluid to be used if residue of chemical is found during
2 Product
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
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
3.1 Chemical names:
consignment is of a hazardous nature.
(a) ....................................................... 5 Signed ……………………………………………….. ...........
(b) .......................................................
Name …………………………………………………
(c) .......................................................
Position ……………………………………………….
(d) .......................................................
Date …………………………………………………..
3.2 Precautions to be taken in
handling these substances:
(a) ........................................................
(b) .......................................................................................................
(c) ........................................................
(d) ........................................................
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
Note: To assist us in our servicing
please describe any fault condition you
have witnessed.