Return of BOC Edwards Equipment - Declaration
Form HS2
You must:
•
Know about all of the substances which have been used and produced in the equipment before you complete this Declaration
•
Read the Return of BOC Edwards Equipment - Procedure (HS1) before you complete this Declaration
•
Contact BOC Edwards to obtain a Return Authorisation Number and to obtain advice if you have any questions
•
Send this form to BOC Edwards before you return your equipment
Return Authorisation Number:
Equipment/System Name_________________________
Part Number _________________________________
Serial Number_________________________________
Has the equipment been used, tested or operated ?
YES
R
Go to Section 2
NO
R
Go to Section 4
IF APPLICABLE:
Tool Reference Number_________________
Process ______________________________
Failure Date___________________________
Serial Number of
Replacement Equipment_________________
Are any substances used or produced in the equipment:
•
Radioactive, biological or infectious agents, mercury,
poly chlorinated biphenyls (PCBs), dioxins
or sodium azide? (if YES, see Note 1) YES
R
NO
R
•
Hazardous to human
health and safety?
YES
R
NO
R
Note 1
: BOC Edwards will not accept delivery of any
equipment that is contaminated with radioactive substances,
biological/infectious agents, mercury, PCB’s, dioxins or
sodium azide, unless you:
•
Decontaminate the equipment
•
Provide proof of decontamination
YOU MUST CONTACT BOC EDWARDS FOR ADVICE
BEFORE YOU RETURN SUCH EQUIPMENT
Print your name:_________________________________Print your job title:_________________________
Print your organisation:____________________________________________________________________
Print your address:_______________________________________________________________________
_______________________________________________________________________
Telephone number: ___________________________Date of equipment delivery: ______________
I have made reasonable enquiry and I have supplied accurate information in this
Declaration. I have not withheld any information, and I have followed the Return of
BOC Edwards Equipment - Procedure (HS1).
Signed: _____________________________________Date______________
•
who did you buy the equipment from ? _____________________________
•
give the supplier’s invoice number_________________________________
If you have a warranty claim:
Substance name
Chemical
Symbol
Precautions required (for example,
use protective gloves, etc.)
Action required after a spill,
leak or exposure
Note: Please print out this
form, sign it and return the
signed form as hard copy.
SECTION 1: EQUIPMENT
SECTION 2: SUBSTANCES IN CONTACT WITH THE EQUIPMENT
SECTION 3: LIST OF SUBSTANCES IN CONTACT WITH THE EQUIPMENT
SECTION 4: RETURN INFORMATION
SECTION 5: DECLARATION
P
900-71-000
I
ssue
K
Reason for return and symptoms of malfunction _________________________________________________
_________________________________________________________________________________