Grundfos DME Instrucciones De Instalación Y Funcionamiento página 89

CERTIFICATE OF CLEANLINESS
HEALTH AND SAFETY CLEARANCE FORM
Please copy, fill in, sign this form and attach it to the pump returned for service along with a return
material authorization number.
Product Description
Product Number
The r The ref ef ef ef efer er er er erenc The r
APPLIC APPLIC APPLIC APPLIC APPLICA A A A A T T T T T ION: ION: ION: ION: The r ION: The r
Y Y Y Y Y ES ES ES ES ES NO NO NO NO NO
S A: T
ECTION
(To be completed if applied substances AR
P P P P P lease specif lease specif lease specif lease specif lease specify all haz y all hazar ar ar ar ardous ma y all haz y all haz y all haz
P P P P P r r r r r o o o o o vide the Ma vide the Ma vide the Material Saf vide the Ma vide the Ma terial Saf terial Saf terial Safety Da terial Saf
tak taken when handling these substanc tak en when handling these substanc en when handling these substanc en when handling these substances. Also
tak tak en when handling these substanc
human con human c human c human c human c on on on ontac tact t t t t wi tac tac tac with an wi wi wi
The produc The pr The pr The pr The pr oduc oduc oduc oduct t t t t r r r r returned has been dec eturned has been dec eturned has been dec eturned has been decon eturned has been dec
P P P P P r r r r r o o o o o vide dec vide decon vide dec vide dec on ontamina on tamina tamination method used. tamina
vide dec on tamina
S B: N
ECTION
(To be completed if applied substances ARE NOT hazardous)
The pr The produc The pr The pr The pr oduc oduc oduct t t t t r r r r returned has not oduc eturned has not handled or been in c eturned has not eturned has not eturned has not
substanc substances. substanc es. es. The pr es. The pr The produc The pr
substanc substanc es. The pr
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.)
C C C C C O O O O O MP MP MP ANY Y Y Y Y NA AN AN NA NA ME ME
MPAN MP AN NAME NA ME ME
NAME NA NA ME ME ME
NA NA ME
SIGNA SIGNA SIGNAT T T T T U U U U U R R R R R E E E E E
SIGNA SIGNA
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 R adioac adioac adioactiv adioac tiv tive pr tiv e pr e produc e pr oduc oduc oducts will not ts will not ts will not be ac ts will not
adioac tiv e pr oduc ts will not
enc enc ed pr ed pr oduc oduct t t t t has been e oduc has been e has been e
enc enced pr ed pr ed produc oduc has been e has been exposed t
If y If y If y If y If yes es es es es, c , c , c , c , complete SEC omplete SECT T T T T ION A omplete SEC omplete SEC omplete SEC
C
OXIC LEARANCE
AR AR ARE E E E E hazardous)
AR
dous ma dous ma dous materials/ dous ma terials/ terials/ terials/substanc terials/
ety Da ety Da ety Da ety Data Sheet ta Sheet f f f f for all ma ta Sheet ta Sheet ta Sheet
es. Also, pr es. Also es. Also
es. Also
th an th an th an th any liquid wi y liquid wi y liquid wi y liquid within the pr y liquid wi thin the pr thin the pr thin the produc thin the pr
on on on ontamina tamina tamina
tion method used. tion method used. tion method used.
tion method used.
-T C
ON OXIC LEARANCE
handled or been in con handled or been in c handled or been in c handled or been in c
oduct t t t t has been dr oduc oduc has been dr has been drained o has been dr ained of liquid and is saf ained o ained o
oduc has been dr ained o
be acc c c c c epted f be ac be ac epted for r epted f epted f or repair or r or r
be ac epted f or r
RMA #
xposed t xposed t o t o to o o o o xic or haz
xposed t xposed to t o t
ION A. If no ION A ION A ION A . If no . If no . If no . If no, c , c , c , c , con
substanc substanc substances used wi substanc es used wi es used wi es used wi es used with the r
or all ma or all ma or all ma or all materials r terials r terials r terials ref ef ef ef efer er er er erenc terials r
, pr , pro o o o o vide an , pr vide an vide an vide any ac y ac y ac y actions t
, pr vide an y ac
oduct t t t t (e (e (e (e (ev v v v v en af oduc oduc oduc en af en af en af en after cleaning and/
tamina taminated, dr ted, dr ted, dr ted, dr ted, drained o ained o ained o ained of liquid and is saf ained o
on on on ontac tact t t t t wi tac tac tac
f liquid and is saf f liquid and is saf f liquid and is safe t
f liquid and is saf
epair. . . . . epair epair
epair
Quantity
o t xic or haz xic or hazar ar ar ar ardous ma xic or haz dous ma dous ma
xic or haz dous materials: dous ma
on on on ontinue t tinue t tinue t tinue t tinue to SEC o SECT T T T T ION B o SEC o SEC o SEC ION B ION B ION B. . . . . ION B
th the r th the ref ef ef ef efer er er er erenc th the r th the r enc enc enced pr enc ed produc ed pr ed pr ed pr
enced or list enc enc enc ed or list ed or list ed or list pr pr pr pr precautions t ed or list ecautions t ecautions t ecautions t ecautions to be
tions t tions to be tak tions t o be tak o be tak o be taken in the e en in the ev v v v v en en in the e en in the e
tions t o be tak en in the e
ter cleaning and/or flushing). ter cleaning and/ ter cleaning and/ ter cleaning and/
f liquid and is saf f liquid and is saf f liquid and is saf f liquid and is safe t e to handle e t e t e t
Ini Ini Ini Ini Initial/Da tial/Da tial/Date te te te te tial/Da tial/Da
wi wi with an wi th an th an th any t th an y t y t y t y to o o o o xic or haz xic or hazar ar ar ar ardous xic or haz xic or haz xic or haz
e t e to handle e t o handle o handle. . . . . o handle
e t o handle
Ini Ini tial/Date te te te te tial/Da tial/Da
Ini Ini Initial/Da tial/Da
P P P P P O O O O O SI SI SI SI SIT T T T T ION ION ION ION
ION
PHONE E E E E PHON PHON
PHON PHON
terials: terials:
terials: terials:
oduc oduct(s oduc oduc t(s). ). ). ). ). t(s t(s t(s
o be o be o be o be
en ent t t t t o o o o of f f f f en
en
or flushing). or flushing). or flushing). or flushing).
o handle o handle o handle. . . . . o handle
dous dous dous dous
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