Watson-marlow 504S User Manual download pdf (Page 14)

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 …………………………………..

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

3.1 Chemical names:

(a)………………..........................

(b)…………….............................

(c)………………..........................

(d)…………….............................

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 consignment is of a hazardous

nature.

5 Signed …………………………………………………………………………………

Name …………………………………………………………………………………

Position ……………………………………………………………………………….

Date …………………………………………………………………………………..

3.2 Precautions to be taken in handling these substances: To assist servicing, please describe any fault

(a)………… .................................................... condition(s) you have witnessed

(b)………… ................................................... …………………………………………………

(d)………………................................................ ……………………………………………………………

3.3 Action to be taken in the event of human contact: ……………………………………………………………………………………………………

(a)…………………………………………………………………. ……………………………………………………………

(b)…………………………………………………………………. ……………………………………………………………

(c)………….……………………………………………………… ……………………………………………………………

(d)………….……………………………………………………… ……………………………………………………………

3.4 Cleaning fluid to be used if residue of chemical is found: ……………………………………………………………

(a)…………………………………………………………………. ……………………………………………………………

(b)…………………………………………………………………. ……………………………………………………………

(c)………….……………………………………………………… ……………………………………………………………

(d)………….……………………………………………………… ……………………………………………………………

Watson-Marlow Bredel Pumps . Falmouth . Cornwall TR11 4RU . England . Tel: 01326 370370 . Fax: 01326 376009

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Watson-marlow 504S User Manual Page 14

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