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Product Use and Decontamination Certificate
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.
RGA No: ...............................................................
1. Company
..............................................................................................................................................................................
Address
..............................................................................................................................................................................
.......................................................................................
Telephone
.......................................................................................
2. Product
..................................................
2.1 Serial number ..................................................
2.2 Has the product been used?
YES
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) ..................................................................................
Note: Please describe current faults
............................................................................................................................................................................................................
............................................................................................................................................................................................................
............................................................................................................................................................................................................
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.
Watson-Marlow Bredel Pumps Falmouth Cornwall TR11 4RU England Tel:+44 (0) 1326 370370 Fax: +44 (0) 1326 376009
NO
If yes, please complete all the following Sections. If no, please complete Section 5 only
...............................................................................................................................................
Postcode
Fax number ........................................................
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 during servicing
(a) ..................................................................................
(b) ..................................................................................
(c) ..................................................................................
(d) ..................................................................................
5. Signed ...................................................................
Name
...................................................................
Position ...................................................................
Date
...................................................................
30
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