Bredel Hose pump Series, Manual

SAFETY FORM

Safety form

SAFETY FORM

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 com-

pleted copy must be attached to 

the outside of the packaging

 containing the item(s). You, the user, are respon-

sible for cleaning and decontaminating the item(s) before returning them. 

Please complete a separate Decontamination Certificate for each item returned. 

RGA/KBR no

...................

1

Company ............................................................. .........................................................................................

Address ................................................................ .........................................................................................

Telephone .............................................................

Postal code...........................................................

Fax number ..........................................................

2

Product  ................................................................

3.4 Cleaning fluid to be used if residue of chemical is 

found during servicing; 

a)   ........................................................................

b)   ........................................................................

c)   ........................................................................

d)   ........................................................................

2.1 Serial Number  ......................................................

2.2 Has the Product been used?

     YES  

     NO  

If yes, please complete all the following para-
graphs.

If no, please complete paragraph 5 only

3

Details of substances pumped

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.

3.1 Chemical Names 

a) ..........................................................................

b) ..........................................................................

c) ..........................................................................

d) ..........................................................................

5

Signed .................................................................

Name ...................................................................

Position ................................................................

Date .....................................................................

3.2 Precautions to be taken in handling these sub-

stances:

a) ..........................................................................

b) ..........................................................................

c) ..........................................................................

d) ..........................................................................

Note:

To assist us in our servicing please describe 
any fault condition you have witnessed.

.............................................................................

.............................................................................

.............................................................................

.............................................................................

.............................................................................

3.3 Action to be taken in the event of human contact:

a)  .........................................................................

b)  .........................................................................

c)   .........................................................................

d)  .........................................................................