ALBIN PUMP ALH - 11 Security Form

60 albinpump@irco.com  Albinpump.com  Albin Pump ALH Instruction Manual
since 1928
ALH
Security Form
11 | SECURITY FORM
In compliance with Health & Safety Regulations you, the user are required to declare the
substances that have been in contact with the product(s) you are returning to ALBIN PUMP 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 ensure that we have the information before receipt of the item(s)
being returned.
A FURTHER 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 certicate for each item returned.
1.0 COMPANY
Company name ...............................
Address .....................................
City .........................................
Postal code ..................................
Country ......................................
Telephone ....................................
Fax number ..................................
2.0 PUMP
2.1 Serial number ...........................
2.2 Has the pump been used ? YES NO
If yes, please complete all the following paragraphs. If no, please complete paragraph 5 only
3.0 Details of substances pumped
3.1 Chemical Names
a)_________________________ b)_________________________ c)_________________________
3.2 Precautions to be taken in handling these substances
a)_________________________ b)_________________________ c)_________________________
3.3 Action to be taken in the event of human contact
a)_________________________ b)_________________________ c)_________________________
3.4 Cleaning fluid to be used if residue of chemical is found during servicing
4.0 I hereby conrm that the only substances(s) that the equipment speci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.
5.0 Signatory authorized
Signed ___________________ Name ___________________
Position __________________ Date ___________________
Remarks: to assist us in our servicing please describe any fault condition you have witnessed.