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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.
1 Company
Address ......... ................................................................... Postcode .............................................
Telephone .................................................... ................. Fax Number .........................................
2.1 Serial Number ... ... ... ... ... ... ... ... ... ... ... ... ... ........... (a)..........................................................
2.2 Has the Product been used?
YES
NO
(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)............................................
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)............................................................................
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
(c).........................................................
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 ...............................................................................................
13
(b).........................................................
To assist servicing, please describe any fault
condition(s) you have witnessed
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RGA No: ........................
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