HEALTH AND SAFETY CLEARANCE FORM
CERTIFICATE OF CLEANLINESS
Please copy, fill in, sign this form and attach it to the pump returned for service along with a return
material authorization number.
APPLICAPPLIC
APPLICAPPLIC
APPLIC
AA
AA
A
TT
TT
T
ION:ION:
ION:ION:
ION:
The rThe r
The rThe r
The r
efef
efef
ef
erer
erer
er
encenc
encenc
enc
ed pred pr
ed pred pr
ed pr
oducoduc
oducoduc
oduc
tt
tt
t
has been e has been e
has been e has been e
has been e
xposed txposed t
xposed txposed t
xposed t
o to t
o to t
o t
oo
oo
o
xic or hazxic or haz
xic or hazxic or haz
xic or haz
arar
arar
ar
dous madous ma
dous madous ma
dous ma
terials:terials:
terials:terials:
terials:
Y
Y
YY
Y
ES NO If yES NO If y
ES NO If yES NO If y
ES NO If y
eses
eses
es
, c, c
, c, c
, c
omplete SEComplete SEC
omplete SEComplete SEC
omplete SEC
TT
TT
T
ION AION A
ION AION A
ION A
. If no. If no
. If no. If no
. If no
, c, c
, c, c
, c
onon
onon
on
tinue ttinue t
tinue ttinue t
tinue t
o SECo SEC
o SECo SEC
o SEC
TT
TT
T
ION BION B
ION BION B
ION B
..
..
.
PP
PP
P
lease speciflease specif
lease speciflease specif
lease specif
y all hazy all haz
y all hazy all haz
y all haz
arar
arar
ar
dous madous ma
dous madous ma
dous ma
terials/terials/
terials/terials/
terials/
substancsubstanc
substancsubstanc
substanc
es used wies used wi
es used wies used wi
es used wi
th the rth the r
th the rth the r
th the r
efef
efef
ef
erer
erer
er
encenc
encenc
enc
ed pred pr
ed pred pr
ed pr
oducoduc
oducoduc
oduc
t(st(s
t(st(s
t(s
).).
).).
).
PP
PP
P
rr
rr
r
oo
oo
o
vide the Mavide the Ma
vide the Mavide the Ma
vide the Ma
terial Saf
terial Saf
terial Safterial Saf
terial Saf
ety Daety Da
ety Daety Da
ety Da
ta Sheetta Sheet
ta Sheetta Sheet
ta Sheet
f f
f f
f
or all maor all ma
or all maor all ma
or all ma
terials rterials r
terials rterials r
terials r
efef
efef
ef
erer
erer
er
encenc
encenc
enc
ed or listed or list
ed or listed or list
ed or list
pr pr
pr pr
pr
ecautions tecautions t
ecautions tecautions t
ecautions t
o beo be
o beo be
o be
taktak
taktak
tak
en when handling these substancen when handling these substanc
en when handling these substancen when handling these substanc
en when handling these substanc
es. Alsoes. Also
es. Alsoes. Also
es. Also
, pr, pr
, pr, pr
, pr
oo
oo
o
vide anvide an
vide anvide an
vide an
y acy ac
y acy ac
y ac
tions ttions t
tions ttions t
tions t
o be tako be tak
o be tako be tak
o be tak
en in the een in the e
en in the een in the e
en in the e
vv
vv
v
enen
enen
en
tt
tt
t
o o
o o
o
ff
ff
f
human chuman c
human chuman c
human c
onon
onon
on
tactac
tactac
tac
tt
tt
t
wi wi
wi wi
wi
th anth an
th anth an
th an
y liquid wiy liquid wi
y liquid wiy liquid wi
y liquid wi
thin the prthin the pr
thin the prthin the pr
thin the pr
oducoduc
oducoduc
oduc
tt
tt
t
(e (e
(e (e
(e
vv
vv
v
en afen af
en af
en af
en af
ter cleaning and/ter cleaning and/
ter cleaning and/ter cleaning and/
ter cleaning and/
or flushing).or flushing).
or flushing).or flushing).
or flushing).
The prThe pr
The prThe pr
The pr
oducoduc
oducoduc
oduc
tt
tt
t
r r
r r
r
eturned has been deceturned has been dec
eturned has been deceturned has been dec
eturned has been dec
onon
onon
on
taminatamina
taminatamina
tamina
ted, drted, dr
ted, drted, dr
ted, dr
ained oained o
ained oained o
ained o
f liquid and is saff liquid and is saf
f liquid and is saff liquid and is saf
f liquid and is saf
e te t
e te t
e t
o handleo handle
o handleo handle
o handle
..
..
.
PP
PP
P
rr
rr
r
oo
oo
o
vide decvide dec
vide decvide dec
vide dec
onon
onon
on
tamina
tamina
taminatamina
tamina
tion method used.tion method used.
tion method used.tion method used.
tion method used.
SECTION A: TOXIC CLEARANCE
(To be completed if applied substances
ARAR
ARAR
AR
EE
EE
E hazardous)
IniIni
IniIni
Ini
tial/Datial/Da
tial/Datial/Da
tial/Da
tete
tete
te
The prThe pr
The prThe pr
The pr
oducoduc
oducoduc
oduc
tt
tt
t
r r
r r
r
eturned has noteturned has not
eturned has noteturned has not
eturned has not
handled or been in c handled or been in c
handled or been in c handled or been in c
handled or been in c
onon
onon
on
tactac
tactac
tac
tt
tt
t
wi wi
wi wi
wi
th anth an
th anth an
th an
y ty t
y ty t
y t
oo
oo
o
xic or hazxic or haz
xic or hazxic or haz
xic or haz
arar
arar
ar
dousdous
dousdous
dous
substancsubstanc
substancsubstanc
substanc
es. es.
es. es.
es.
The prThe pr
The prThe pr
The pr
oducoduc
oducoduc
oduc
t
t
tt
t
has been dr has been dr
has been dr has been dr
has been dr
ained oained o
ained oained o
ained o
f liquid and is saff liquid and is saf
f liquid and is saff liquid and is saf
f liquid and is saf
e te t
e te t
e t
o handleo handle
o handleo handle
o handle
..
..
.
SECTION B: NON-TOXIC CLEARANCE
(To be completed if applied substances ARE NOT hazardous)
IniIni
IniIni
Ini
tial/Datial/Da
tial/Datial/Da
tial/Da
tete
tete
te
I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name
and are classified, packed, marked and labeled, and are in all respects in proper condition for transport, by all modes,
according to applicable international and national governmental regulations. Health and safety issues are clearly
understood and will be given consideration during shipment. (A repair or inspection of product will only be undertaken
when this certificate has been completed and authorized by a qualified member of staff employed by the returning
company.)
Product Description
Product Number RMA # Quantity
CC
CC
C
OO
OO
O
MPMP
MPMP
MP
ANAN
ANAN
AN
YY
YY
Y
NANA
NANA
NA
MEME
MEME
ME
NANA
NANA
NA
MEME
MEME
ME
PP
PP
P
OO
OO
O
SISI
SISI
SI
TT
TT
T
IONION
IONION
ION
SIGNASIGNA
SIGNASIGNA
SIGNA
TT
TT
T
UU
UU
U
RR
RR
R
EE
EE
E
PHONPHON
PHONPHON
PHON
EE
EE
E
A return material authorization number from Grundfos, along with a completed and signed copy of this form must
accompany the returned product. It is the senders responsibility to package, transport and complete the shipping documents
regarding the nature of the product shipped. Irrespective of this, Grundfos reserves the right to reject the service order for
other reasons. Grundfos will rely on this representation and will look to the customer for reimbursement of any and all
costs, claims or damages incurred, including attorney’s fees, if any representation is not correct.
RR
RR
R
adioacadioac
adioacadioac
adioac
tivtiv
tivtiv
tiv
e pre pr
e pre pr
e pr
oducoduc
oducoduc
oduc
ts will notts will not
ts will notts will not
ts will not
be ac be ac
be ac be ac
be ac
cc
cc
c
epted fepted f
epted fepted f
epted f
or ror r
or ror r
or r
epairepair
epairepair
epair
..
..
.
To Next Page
Loading...
Need help?
General
