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12
Veiligheidsformulier
Product Use and Decontamination Declaration
In compliance with the Health and Safety Regulations, the user is required to declare those
substances that have been in contact with the item(s) you are returning to Watson-Marlow Bredel
B.V. or any of its subsidiaries or distributors. Failure to do so will cause delays in servicing the
item or in issuing a response. Therefore, please complete this form to make sure we have the
information before receipt of the item(s) being returned. A completed copy must be attached to
the outside of the packaging containing the item(s). You, the user, are responsible for cleaning
and decontaminating the item(s) before returning them.
Please complete a separate Decontamination Certifi cate for each item returned.
RGA/KBR no...................
1
C
o
m
p
a
y n
. . . .
. . . .
A
d
d
e r
s
. s
. . . .
. . . .
Telephone ..................................................................
2
Product .....................................................
2.1 Serial Number ..........................................
2.2 Has the Product been used?
YES
f I
e y
, s
p
e l
a
s
e
c
paragraphs.
If no, please complete paragraph 5 only
3
D
e
a t
s l i
o
s f
u
b
s
3.1 Chemical Names
a) ................................................................
b) ...............................................................
c) ................................................................
d) .................................................................
3
2 .
P
e r
c
a
t u
o i
n
s
o t
substances:
a) ...............................................................
b) ...............................................................
c) ................................................................
d) ...............................................................
3
3 .
A
t c
o i
n
o t
b
e
a t
e k
contact:
a) ...............................................................
b) ...............................................................
c) ................................................................
d) ...............................................................
m-bredel-25-32-nl-05
. . . .
. . . .
. . . .
. . . .
. . . .
. . . .
. . . .
. . . .
................................................................................................
. . . .
. . . .
. . . .
. . . .
. . . .
. . . .
. . . .
. . . .
..................................................................................................
NO
o
m
p
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e t
l l a
h t
e
o f
o l l
w
n i
a t
n
c
e
s
p
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d
b
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e k
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n
n i
h t
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e
e v
t n
f o
h
u
m
Postal code ........................................
F
a
x
n
3
4 .
C
e l
a
n
n i
g
fl
chemical is found during servicing;
a) ...............................................................
b) ...............................................................
c) ................................................................
g
d) ...............................................................
4
I
h
e
e r
y b
c
o
substances(s) that the equipment specifi ed
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 ......................................................
e
s
e
Name ........................................................
Position .....................................................
Date ..........................................................
Note:
T
o
a
s
i s
t s
u
describe any fault condition you have
a
n
witnessed.
....................................................................
....................................................................
....................................................................
....................................................................
....................................................................
u
m
b
e
. r
. . . .
. . . .
. . . .
. . . .
. . . .
. . . .
. . . .
u
d i
o t
b
e
u
s
e
d
f i
e r
s
d i
u
e
n
r fi
m
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t a
h t
e
o
n
y l
s
n i
o
r u
s
e
v r
c i
n i
g
p
e l
a
. . .
. . . .
....
f o
s
e
107
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