Watson-Marlow 313F - Manuel (Page 15)

80
Watson-Marlow, Le Marprène et le Bioprène sont des marques de fabrique Watson-Marlow Limited
Tygon est une marque de fabrique de la Société Norton
Attention, Ces produits ne sont pas étudiéspour un usage interne et ne doivent pas être utilisés pour des
applications en liaison directe avec les malades.
Les descriptions et caractéristiques figurant sur ce document sont données à titre d'information et non d'engagement
contractuel. Watson-Marlow Limited se réserve le droit d'effectuer sans préavis, toute modification.
Product use and decontamination declaration
In compliance with the UK Health & Safety at Work Act and the Control of Substances Hazardous to Health
Regulations you, the user are required to declare the substances which have been in contact with the product(s) you
are returning to Watson-Marlow or any of its subsidiaries or distributors. Failure to do so will cause delays in servicing
the product. Therefore, please complete this form to ensure that we have the information before receipt of the
product(s) being returned. A FURTHER COPY MUST BE ATTACHED TO THE OUTSIDE OF THE PACKAGING
CONTAINING THE PRODUCT(S). You, the user, are responsible for cleaning and decontaminating the product(s)
before returning them.
Please complete a separate Decontamination Certificate for each pump returned. RGA No: …………………...
1 Company
Address ……… .................................................................. Postcode ………………………………………
Telephone ……………………………………………. ................ Fax Number …………………………………..
2.1 Serial Number … … … … … … … … … … … … … ........... (a)………………………………………………….
2.2 Has the Product been used? (b)…………………………………………………
YES NO (c)…………………………………………………
(d)…………………………………………………
If yes, please complete all the following Sections. If no, please complete Section 5 only
3 Details of substances pumped
3.1 Chemical names:
(a)………………..........................
(b)…………….............................
(c)………………..........................
(d)…………….............................
4 I hereby confirm that the only substances(s) that the equipment specified 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 …………………………………………………………………………………..
3.2 Precautions to be taken in handling these substances: To assist servicing, please describe any fault
(a)………… .................................................... condition(s) you have witnessed
(b)………… ................................................... …………………………………………………
(c) ………………............................................... ……………………………………………………………
(d)………………................................................ ……………………………………………………………
3.3 Action to be taken in the event of human contact: ……………………………………………………………………………………………………
(a)…………………………………………………………………. ……………………………………………………………
(b)…………………………………………………………………. ……………………………………………………………
(c)………….……………………………………………………… ……………………………………………………………
(d)………….……………………………………………………… ……………………………………………………………
3.4 Cleaning fluid to be used if residue of chemical is found: ……………………………………………………………
(a)…………………………………………………………………. ……………………………………………………………
(b)…………………………………………………………………. ……………………………………………………………
(c)………….……………………………………………………… ……………………………………………………………
(d)………….……………………………………………………… ……………………………………………………………
Watson-Marlow Bredel Pumps . Falmouth . Cornwall TR11 4RU . England . Tel: 01326 370370 . Fax: 01326 376009