89
HEALTH
AND
SAFETY
CLEARANCE
FORM
CERTIFICATE OF CLEANLINESS
Please copy, fill in, sign this form and attach it to the pump returned for service along with a return
material authorization number.
APPLIC
APPLIC
APPLIC
APPLIC
APPLICA
A
A
A
AT
TT
T
TION:
ION:
ION:
ION:
ION:
The r
The r
The r
The r
The ref
ef
ef
ef
efer
er
er
er
erenc
enc
enc
enc
enced pr
ed pr
ed pr
ed pr
ed produc
oduc
oduc
oduc
oducttttt has been e
has been e
has been e
has been e
has been exposed t
xposed t
xposed t
xposed t
xposed to t
o t
o t
o t
o to
o
o
o
oxic or haz
xic or haz
xic or haz
xic or haz
xic or hazar
ar
ar
ar
ardous ma
dous ma
dous ma
dous ma
dous materials:
terials:
terials:
terials:
terials:
Y
YY
YYES NO If y
ES NO If y
ES NO If y
ES NO If y
ES NO If yes
es
es
es
es, c
, c
, c
, c
, complete SEC
omplete SEC
omplete SEC
omplete SEC
omplete SECT
TT
T
TION A
ION A
ION A
ION A
ION A. If no
. If no
. If no
. If no
. If no, c
, c
, c
, c
, con
on
on
on
ontinue t
tinue t
tinue t
tinue t
tinue to SEC
o SEC
o SEC
o SEC
o SECT
TT
T
TION B
ION B
ION B
ION B
ION B.....
P
PP
PPlease specif
lease specif
lease specif
lease specif
lease specify all haz
y all haz
y all haz
y all haz
y all hazar
ar
ar
ar
ardous ma
dous ma
dous ma
dous ma
dous materials/
terials/
terials/
terials/
terials/substanc
substanc
substanc
substanc
substances used wi
es used wi
es used wi
es used wi
es used with the r
th the r
th the r
th the r
th the ref
ef
ef
ef
efer
er
er
er
erenc
enc
enc
enc
enced pr
ed pr
ed pr
ed pr
ed produc
oduc
oduc
oduc
oduct(s
t(s
t(s
t(s
t(s).
).
).
).
).
P
PP
PPrrrrro
o
o
o
ovide the Ma
vide the Ma
vide the Ma
vide the Ma
vide the Material Saf
terial Saf
terial Saf
terial Saf
terial Safety Da
ety Da
ety Da
ety Da
ety Data Sheet
ta Sheet
ta Sheet
ta Sheet
ta Sheet f
f
f
f
for all ma
or all ma
or all ma
or all ma
or all materials r
terials r
terials r
terials r
terials ref
ef
ef
ef
efer
er
er
er
erenc
enc
enc
enc
enced or list
ed or list
ed or list
ed or list
ed or list pr
pr
pr
pr
precautions t
ecautions t
ecautions t
ecautions t
ecautions to be
o be
o be
o be
o be
tak
tak
tak
tak
taken when handling these substanc
en when handling these substanc
en when handling these substanc
en when handling these substanc
en when handling these substances. Also
es. Also
es. Also
es. Also
es. Also, pr
, pr
, pr
, pr
, pro
o
o
o
ovide an
vide an
vide an
vide an
vide any ac
y ac
y ac
y ac
y actions t
tions t
tions t
tions t
tions to be tak
o be tak
o be tak
o be tak
o be taken in the e
en in the e
en in the e
en in the e
en in the evvvvven
en
en
en
enttttt o
o
o
o
offfff
human c
human c
human c
human c
human con
on
on
on
ontac
tac
tac
tac
tacttttt wi
wi
wi
wi
with an
th an
th an
th an
th any liquid wi
y liquid wi
y liquid wi
y liquid wi
y liquid within the pr
thin the pr
thin the pr
thin the pr
thin the produc
oduc
oduc
oduc
oducttttt (e
(e
(e
(e
(evvvvven af
en af
en af
en af
en after cleaning and/
ter cleaning and/
ter cleaning and/
ter cleaning and/
ter cleaning and/or flushing).
or flushing).
or flushing).
or flushing).
or flushing).
The pr
The pr
The pr
The pr
The produc
oduc
oduc
oduc
oducttttt r
r
r
r
returned has been dec
eturned has been dec
eturned has been dec
eturned has been dec
eturned has been decon
on
on
on
ontamina
tamina
tamina
tamina
taminated, dr
ted, dr
ted, dr
ted, dr
ted, drained o
ained o
ained o
ained o
ained of liquid and is saf
f liquid and is saf
f liquid and is saf
f liquid and is saf
f liquid and is safe t
e t
e t
e t
e to handle
o handle
o handle
o handle
o handle.....
P
PP
PPrrrrro
o
o
o
ovide dec
vide dec
vide dec
vide dec
vide decon
on
on
on
ontamina
tamina
tamina
tamina
tamination method used.
tion method used.
tion method used.
tion method used.
tion method used.
S
ECTION
A: T
OXIC
C
LEARANCE
(To be completed if applied substances AR
AR
AR
AR
AREEEEE hazardous)
Ini
Ini
Ini
Ini
Initial/Da
tial/Da
tial/Da
tial/Da
tial/Date
te
te
te
te
The pr
The pr
The pr
The pr
The produc
oduc
oduc
oduc
oducttttt r
r
r
r
returned has not
eturned has not
eturned has not
eturned has not
eturned has not handled or been in c
handled or been in c
handled or been in c
handled or been in c
handled or been in con
on
on
on
ontac
tac
tac
tac
tacttttt wi
wi
wi
wi
with an
th an
th an
th an
th any t
y t
y t
y t
y to
o
o
o
oxic or haz
xic or haz
xic or haz
xic or haz
xic or hazar
ar
ar
ar
ardous
dous
dous
dous
dous
substanc
substanc
substanc
substanc
substances.
es.
es.
es.
es. The pr
The pr
The pr
The pr
The produc
oduc
oduc
oduc
oducttttt has been dr
has been dr
has been dr
has been dr
has been drained o
ained o
ained o
ained o
ained of liquid and is saf
f liquid and is saf
f liquid and is saf
f liquid and is saf
f liquid and is safe t
e t
e t
e t
e to handle
o handle
o handle
o handle
o handle.....
S
ECTION
B: N
ON
-T
OXIC
C
LEARANCE
(To be completed if applied substances
ARE NOT
hazardous)
Ini
Ini
Ini
Ini
Initial/Da
tial/Da
tial/Da
tial/Da
tial/Date
te
te
te
te
I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name
and are classified, packed, marked and labeled, and are in all respects in proper condition for transport, by all modes,
according to applicable international and national governmental regulations. Health and safety issues are clearly
understood and will be given consideration during shipment. (A repair or inspection of product will only be undertaken
when this certificate has been completed and authorized by a qualified member of staff employed by the returning
company.)
Product Description
Product Number
RMA # Quantity
C
C
C
C
CO
O
O
O
OMP
MP
MP
MP
MPAN
AN
AN
AN
ANY
Y
Y
Y
Y
NA
NA
NA
NA
NAME
ME
ME
ME
ME
NA
NA
NA
NA
NAME
ME
ME
ME
ME
P
P
P
P
PO
O
O
O
OSI
SI
SI
SI
SIT
TT
T
TION
ION
ION
ION
ION
SIGNA
SIGNA
SIGNA
SIGNA
SIGNAT
TT
T
TU
U
U
U
UR
R
R
R
RE
EE
EE
PHON
PHON
PHON
PHON
PHONE
EE
EE
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.
R
R
R
R
Radioac
adioac
adioac
adioac
adioactiv
tiv
tiv
tiv
tive pr
e pr
e pr
e pr
e produc
oduc
oduc
oduc
oducts will not
ts will not
ts will not
ts will not
ts will not be ac
be ac
be ac
be ac
be accccccepted f
epted f
epted f
epted f
epted for r
or r
or r
or r
or repair
epair
epair
epair
epair.....
Grundfos.bk Page 89 Wednesday, May 21, 2008 11:21 AM
