Grundfos DME Serie Instrucciones De Instalación Y Funcionamiento página 109

Appendix
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
APPLIC APPLICA A A A A T T T T T ION: APPLIC ION: ION: The r The ref ef ef ef efer er er er erenc The r
APPLIC APPLIC ION: ION: The r The r
Y Y Y Y Y ES ES ES ES ES
S A: T
ECTION
(To be completed if applied substances AR
P P P P P lease specif lease specif lease specif lease specify all haz lease specif y all haz y all haz y all hazar ar ar ar ardous ma 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 Ma vide the Ma vide the Material Saf terial Saf terial Saf terial Safety Da terial Saf
tak taken when handling these substanc tak tak tak en when handling these substanc en when handling these substances. Also en when handling these substanc en when handling these substanc
human con human c human c human c human c on on ontac on tact t t t t wi tac tac tac with an wi wi wi
The pr The pr oduc oduct t t t t r r r r returned has been dec oduc eturned has been dec eturned has been dec
The produc The pr The pr oduc eturned has been dec eturned has been decon
P P P P P r r r r r o o o o o vide dec vide dec vide dec vide decon vide dec ontamina on on on tamina tamina tamina tamination method used.
S B: N
ECTION
(To be completed if applied substances ARE NOT hazardous)
The produc The pr The pr The pr The pr oduc oduc oduct t t t t r r r r returned has not oduc eturned has not eturned has not handled or been in c eturned has not eturned has not
substances. substanc substanc substanc substanc es. es. The pr es. es. The produc The pr The pr 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 MPAN MP AN AN AN ANY Y Y Y Y NA NA NA NA NAME ME ME ME ME
NA NA NA NAME NA ME ME ME ME
SIGNA SIGNAT T T T T U U U U U R R R R R E E E E E SIGNA 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 adioactiv adioac adioac tiv tive pr tiv e pr e produc e pr oducts will not oduc oduc ts will not be ac ts will not ts will not
adioac tiv e pr oduc ts will not
enc enc ed pr ed pr oduc oduc oduct t t t t has been e has been e has been e
enc enced pr ed pr ed produc oduc has been e has been exposed t
NO NO NO NO NO If y If y If y If y If yes es es es es, c , c , c , c , complete SEC omplete SEC omplete SEC omplete SECT T T T T ION A omplete SEC
C
OXIC LEARANCE
AR ARE E E E E hazardous) AR AR
dous materials/ dous ma dous ma dous ma terials/substanc terials/ terials/ terials/
ety Da ety Data Sheet ety Da ety Da ta Sheet ta Sheet ta Sheet f f f f for all ma ta Sheet
es. Also es. Also es. Also, pr es. Also
th an th any liquid wi th an th an y liquid wi y liquid wi y liquid within the pr y liquid wi thin the pr thin the pr thin the pr thin the produc
on on tamina tamina
ontamina on tamina taminated, dr
tion method used. tion method used. tion method used. tion method used.
-T C
ON OXIC LEARANCE
handled or been in c handled or been in c handled or been in c handled or been in con
oduc oduct t t t t has been dr oduc oduc has been dr has been dr has been drained o has been dr ained of liquid and is saf ained o ained o ained o
be ac be ac be acc c c c c epted f epted for r epted f epted f or r or r or repair epair. . . . . epair epair
be ac epted f or r epair
RMA #
xposed t xposed t o to o o o o xic or haz o t o t
xposed t xposed to t o t
ION A ION A ION A. If no ION A . If no . If no, c , c , c , c , con . If no . If no on ontinue t on on
substanc substances used wi substanc substanc es used wi es used wi es used with the r es used wi th the ref ef ef ef efer er er er erenc th the r th the r th the r
or all ma or all ma or all materials r or all ma terials ref ef ef ef efer er er er erenc terials r terials r terials r enced or list enc enc enc
, pr , pro o o o o vide an , pr , pr vide an vide an vide an vide any ac y ac y ac y actions t y ac tions t tions t tions t tions to be tak
oduc oduc oduc oduct t t t t (e (e (e (e (ev v v v v en af en af en af en af en after cleaning and/ ter cleaning and/ ter cleaning and/ ter cleaning and/or flushing). ter cleaning and/
ted, dr ted, dr ained o ained o f liquid and is saf f liquid and is saf
ted, dr ted, drained o ained of liquid and is saf ained o f liquid and is saf f liquid and is safe t
ontac on on on tact t t t t wi tac tac tac with an wi wi wi th any t th an th an th an
f liquid and is safe t f liquid and is saf f liquid and is saf f liquid and is saf
PHON PHON PHONE E E E E PHON PHON
Quantity
xic or hazar ar ar ar ardous ma xic or haz xic or haz dous ma dous ma terials: terials:
xic or haz dous ma dous materials: terials: terials:
tinue t tinue to SEC tinue t tinue t o SEC o SEC o SEC o SECT T T T T ION B ION B ION B ION B. . . . . ION B
enc enced pr enc enc ed pr ed produc ed pr ed pr oduc oduc oduc oduct(s
ed or list ed or list ed or list ed or list pr pr pr pr precautions t ecautions to be ecautions t ecautions t ecautions t
o be tak o be taken in the e o be tak o be tak en in the ev v v v v en en in the e en in the e en in the e
or flushing). or flushing). or flushing). or flushing).
e t e t o handle o handle o handle. . . . .
e t e to handle o handle
Initial/Da Ini Ini Ini Ini tial/Da tial/Da tial/Da tial/Date te te te te
y to o o o o xic or haz y t y t y t xic or haz xic or haz xic or haz xic or hazar ar ar ar ardous dous dous dous dous
e to handle e t e t e t o handle o handle o handle o handle. . . . .
Ini Ini Ini Ini Initial/Da tial/Da tial/Da tial/Da tial/Date te te te te
P P P P P O O O O O SI SI SI SI SIT T T T T ION ION ION ION ION
1
t(s). ). ). ). ). t(s t(s t(s
o be o be o be o be
ent t t t t o o o o of f f f f en en en
109