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Product use and decontamination declaration
In c ompliance with the UK Health & Safety at Work Act and the Control of Substances Hazardous to Health
Regulations you, the us er are required to dec lare the s ubstances which have been in c ontact with the pr oduct(s)
you ar e r eturning to W atson-Marlow or any of its s ubsidiaries or dis tributors. F ailure 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 pr oduct(s) being r eturned. 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.
No: ........................
1 Company
Address
...................................................
Telephone
................................................
2
Product
2.1 Serial Number .......................................
2.2 Has the Product been used?
YES
NO
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)............ ............................................................................Note: To assist us in our servicing
(c) .....................................................................
(d)................... ..................................................
3.3 Action to be taken in the event of human contact:
(a)............................................................................
(b)............................................................................
(c)............................................................................
(d)............................................................................
Watson-Marlow Limited Falmouth Cornwall TR11 4RU England Tel: 01326 370370 Fax: 01326 376009
Postcode .............................................
Fax Number .........................................
3.4 Cleaning fluid to be used if residue of chemical is found during
servicing;
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 ...........................................................
39
(a)..........................................................
(b).........................................................
(c).........................................................
(d).........................................................
please describe any fault condition you
have witnessed.
RGA
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