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 retu
rned. 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...................
............... ......................... ynapmoC 1 ................................................................................................
............. ............................ sserddA ..................................................................................................
Telephone .................................................................. Postal code ........................................
.......
............................. rebmun xaF ....
2 Product .....................................................
2.1 Serial Number ..........................................
2.2 Has the Product been used?
YES NO
gniwollof eht lla etelpmoc esaelp ,sey fI
paragraphs.
If no, please complete paragraph 5 only
depmup secnatsbus fo sliateD 3
3.1 Chemical Names
a) ................................................................
b) ...............................................................
c) ................................................................
d) .................................................................
eseht gnildnah ni nekat eb ot snoituacerP 2.3
substances:
a) ...............................................................
b) ...............................................................
c) ................................................................
d) ...............................................................
namuh fo tn
eve eht ni nekat eb ot noitcA 3.3
contact:
a) ...............................................................
b) ...............................................................
c) ................................................................
d) ...............................................................
fo eudiser fi desu eb ot diu fl gninaelC 4.3
chemical is found during servicing;
a) ...............................................................
b) ...............................................................
c) ................................................................
d) ...............................................................
ylno eht taht mr finoc ybereh I 4
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 ......................................................
Name ........................................................
Position .....................................................
Date ..........................................................
Note:
esaelp gnicivres ruo ni su tsissa oT
describe any fault condition you have
witnessed.
....................................................................
....................................................................
....................................................................
....................................................................
....................................................................
Product Use and Decontamination Declaration
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