SAFETY FORM
25
SAFETY FORM
WARNING
A complaint will only be handled by Bredel if this Safety Form is fully completed and
digitally send to Bredel before shipment is activated. A hardcopy of this form is to be
attached to the outside of the packaging including MSDS sheet or similar safety
information sheet if applicable for each item returned.
Product Use and Decontamination Declaration
TS16-002 rev. 0
In compliance with our
Health & Safety Regulations
, the user is required to declare any substances that have been in
contact with the item(s) being returned to Watson-Marlow Bredel B.V. or any of its subsidiaries or distributors. Not following
these requirements may lead to delays in service and/ or response time. Full completion of this form assures we are
provided with necessary information before receipt of the item(s) being returned. A hardcopy of the completed form must be
attached to
the outside of the packaging
containing the item(s). The sender of the item(s) is responsible for cleaning and
decontaminating of the item(s) before returning them in such way that it is safe for the receiver to open the packaging and
handle the item(s).
Complaint number:
...........................
1.
Company:
…………………………………………………………………………….……………………….……………
Address:
...……………………………….…….
Contact person: …….……………………………….
Telephone:
………….……………………………
Postal code: ………………..…………………………………
Email address: ………………..………………………………
Fax number: ..………………………………………………...
2.
Product:
…………………………………….…
3.4 Cleaning fluid to be used if residue of chemical is found
during service:
(a)
……………………………………………….…
(b)
……………………………………………….…
(c)
…………………………………………….……
(d)
…………………………………….……….…
2.1 Serial Number:…………………………………….
2.2 Has the Product been used?
o
Yes
(Go to section 3)
o
No
(Go to section 5)
3.
Details of substances pumped
4.
o
I hereby confirm that the only substance(s) that the
equipment specified has pumped or come into
contact with those named, that the information given
is correct and the carrier has been informed if the
consignment is of a hazardous nature.
3.1 Chemicals names:
(a)
………………………………..……..……….
(b)
……………………………….……………….
(c)
…………………………………….…....……
(d)
..…………………………………...………….
5. Signed:
……………………………..……………
Name:
…………………..……...……………….
Position:
………………………………..…………
Date:
……………………………….………….
3.2 Precautions to be taken in handling these
substances:
(a)
………………………………………………..
(b)
…………………………………………….….
(c)
………………………………………………..
(d)
………………………………………………..
Note:
To assist us in our service, please describe any fault
condition you have witnessed.
……………………………………………………………
……………………………………………………………
……………………………………………………………
……………………………………………………………
Quantity of sheets attached: …………………………
3.3 Actions to be taken in event of human contact:
(a)
………………………………………………..
(b)
…………………………………………….….
(c)
………………………………………………..
(d)
………………………………………………..
