Return of Edwards Equipment – Declaration
Form HS2
You must:
•Know about all of the substances which have been used and produced in the equipment before you complete this Declaration
• Read the Return of Edwards Equipment – Procedure (HS1) before you complete this Declaration
• Contact Edwards to obtain a Return Authorisation Number and to obtain advice if you have any questions
• Send this form to Edwards before you return your equipment as per the procedure in HS1
Return Authorisation Number:
Manufacturer's Product Name _________________________
Manufacturer's Part Number ___________________________
Manufacturer's Serial Number _________________________
Has the equipment been used, tested or operated?
YES, Used or operated Go to Section 2
YES, Tested, but not connected to any process or
production equipment, and only exposed to Nitrogen,
Helium or Air Go to Section 4
NO Go to Section 4
IF APPLICABLE:
Tool Identification Number ___________________________
Tool Manufacturer/OEM ______________________________
Tool Model _________________________________________
Process ___________________________________________
Installed Date ____________ De-installed Date ___________
Part Number of Replacement Equipment _______________
Serial Number of Replacement Equipment ______________
Pump datalog attached? YES NO
(Edwards Internal Use Only)
Are any substances used or produced in the equipment:
•
Radioactive, biological or infectious agents, mercury,
poly chlorinated biphenyls (PCBs), dioxins or
sodium azide? (if YES, see Note 1) YES
NO
•
Hazardous to human
health and safety? YES
NO
Note 1: Edwards will not accept delivery of any equipment
that is contaminated with radioactive substances, biological/
infectious agents, mercury, PCB’s, dioxins or sodium azide,
unless you:
• Decontaminate the equipment
• Provide proof of decontamination
YOU MUST CONTACT EDWARDS FOR ADVICE BEFORE YOU RETURN
SUCH EQUIPMENT
Print your name: _________________________________ Print your job title: ____________________________________
Print your organisation: ____________________________________________________________________________________
Print your address: _____________________________________________________________________________________
_____________________________________________________________________________________________________
Telephone number: ___________________________ Date of equipment delivery: ____________________________________
I have made reasonable enquiry and I have supplied accurate information in this Declaration. I have not withheld any
information, and I have followed the Return of Edwards Equipment – Procedure (HS1).
Signed: _____________________________________ Date: ____________________
• who did you buy the equipment from? ______________________________
____
_
____
_
__
•
give the supplier’s invoice number
_________
__________________
____
_
____
_
__
_
___
_
If you have a warranty claim:
Substance name
Chemical
Symbol
Precautions required (for example,
use protective gloves, etc.)
Action required after a spill,
leak or exposure
Note: Please print out this
form, sign it and return the
signed form as hard copy.
SECTION 1: EQUIPMENT
SECTION 2: SUBSTANCES IN CONTACT WITH THE EQUIPMENT
SECTION 3: LIST OF SUBSTANCES IN CONTACT WITH THE EQUIPMENT
SECTION 4: RETURN INFORMATION
SECTION 5: DECLARATION
P900-71-000 Issue N
Reason for return and symptoms of malfunction: ________________________________________________________________
__________________________________________________________________________________________________________
For how many hours has the product run? ___________ Do you wish to purchase a full Failure Analysis report? YES
NO
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