Product return or servicing
Health & Safety Declaration Form
for Product Return or Servicing
Return authorization
number:
and/or
Service Ticket/Request:
To make sure the mutual protection and safety of GE personnel, our customers, transportation personnel and our environment,
all equipment must be clean and free of any hazardous contaminants before shipping to GE. To avoid delays in the processing of
your equipment, please complete this checklist and include it with your return.
1.
Please note that items will NOT be accepted for servicing or return without this form
2.
Equipment which is not sufficiently cleaned prior to return to GE may lead to delays in servicing the equipment and
could be subject to additional charges
3.
Visible contamination will be assumed hazardous and additional cleaning and decontamination charges will be applied
Yes
No
Please specify if the equipment has been in contact with any of the following:
Radioactivity (please specify)
Infectious or hazardous biological substances (please specify)
Other Hazardous Chemicals (please specify)
Equipment must be decontaminated prior to service / return. Please provide a telephone number where GE can contact
you for additional information concerning the system / equipment.
Telephone No:
Liquid and/or gas in equipment is:
Water
Ethanol
None, empty
Argon, Helium, Nitrogen
Liquid Nitrogen
Other, please
specify
Equipment type / Product No:
Serial No:
I hereby confirm that the equipment specified above has been cleaned to remove any hazardous substances and that the
area has been made safe and accessible.
Name:
Company or
institution:
Position or job title:
Date (YYYY/MM/DD)
Signed:
To receive a return authorization number or service number,
please call local technical support or customer service.
GE and GE monogram are trademarks of General Electric Company.
GE Healthcare Bio-Sciences Corp, 800 Centennial Avenue, P.O. Box 1327, Piscataway,
NJ 08855-1327, US
© 2010-14 General Electric Company—All rights reserved. First published April 2010.
DOC1149544/
28-9800-27 AC 05/2014
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Peristaltic Pump P-1 Operating Instructions 28962201 AF
7 Reference information
7.3 Health and Safety Declaration Forms
