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
R
Go to Section 2 NO
R
Go to Section 4
IF APPLICABLE:
Tool Reference Number _____________________
Process _______________________________________
Failure Date _______________________________
Serial Number of
Replacement Equipment ______________________
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
R
NO
R
•
Hazardous to human
health and safety? YES
R
NO
R
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 ofEdwards 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 M
Reason for return and symptoms of malfunction: ____________________________________________________________
______________________________________________________________________________________________________
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