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Annexe
CERTIFICATE OF CLEANLINESS
HEALTH AND SAFETY CLEARANCE FORM
Please copy, fill in, sign this form and attach it to the pump returned for service along with a return
material authorization number.
Product Description
Product Number
The r
The ref ef ef ef efer er er er erenc
The r
APPLICA A A A A T T T T T ION:
APPLIC
APPLIC
APPLIC
APPLIC
ION: The r
ION:
ION:
ION:
The r
Y Y Y Y Y ES
ES
ES
ES
ES
S
A: T
ECTION
(To be completed if applied substances AR
P P P P P lease specif
lease specif
lease specif
lease specify all haz
y all haz
y all hazar ar ar ar ardous ma
y all haz
lease specif
y all haz
P P P P P r r r r r o o o o o vide the Ma
vide the Material Saf
vide the Ma
vide the Ma
vide the Ma
terial Safety Da
terial Saf
terial Saf
terial Saf
tak
tak
tak
taken when handling these substanc
tak
en when handling these substanc
en when handling these substanc
en when handling these substances. Also
en when handling these substanc
human con
human c
human c
human c
human c
on
ontac
on
on
tac
tac
tact t t t t wi
tac
wi
wi
with an
wi
The pr
The pr
The produc
The pr
The pr
oduc
oduc
oduct t t t t r r r r returned has been dec
oduc
eturned has been decon
eturned has been dec
eturned has been dec
eturned has been dec
P P P P P r r r r r o o o o o vide dec
vide dec
vide dec
vide decon
vide dec
ontamina
on
on
on
tamination method used.
tamina
tamina
tamina
S
B: N
ECTION
(To be completed if applied substances ARE NOT hazardous)
The pr
The pr
The produc
oduct t t t t r r r r returned has not
oduc
oduc
eturned has not
eturned has not
eturned has not handled or been in c
The pr
The pr
oduc
eturned has not
substanc
substances.
substanc
substanc
substanc
es.
es. The pr
es.
es.
The produc
The pr
The pr
The pr
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.)
C C C C C O O O O O MP
MP
MP
MPAN
MP
ANY Y Y Y Y NA
AN
AN
AN
NA
NAME
NA
NA
ME
ME
ME
ME
NA
NA
NA
NAME
NA
ME
ME
ME
ME
SIGNA
SIGNA
SIGNAT T T T T U U U U U R R R R R E E E E E
SIGNA
SIGNA
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.
R R R R R adioac
adioactiv
adioac
adioac
tive pr
tiv
tiv
e produc
e pr
e pr
oduc
oduc
oducts will not
ts will not
ts will not be ac
ts will not
adioac
tiv
e pr
oduc
ts will not
32
enc
enc
ed pr
ed pr
oduc
oduct t t t t has been e
oduc
has been e
has been e
enc
enced pr
ed pr
ed produc
oduc
has been exposed t
has been e
NO
NO
NO
NO
NO
If y
If y
If y
If y
If yes es es es es, c , c , c , c , complete SEC
omplete SECT T T T T ION A
omplete SEC
omplete SEC
omplete SEC
C
OXIC
LEARANCE
AR
AR
AR
ARE E E E E hazardous)
dous materials/
dous ma
dous ma
terials/
terials/
terials/substanc
substanc
dous ma
terials/
substanc
ety Da
ety Da
ety Data Sheet
ety Da
ta Sheet f f f f for all ma
ta Sheet
ta Sheet
ta Sheet
es. Also
es. Also, pr
es. Also
es. Also
th an
th an
th an
th any liquid wi
y liquid within the pr
y liquid wi
y liquid wi
y liquid wi
thin the pr
thin the pr
thin the pr
thin the produc
ontamina
on
on
on
tamina
taminated, dr
tamina
tamina
tion method used.
tion method used.
tion method used.
tion method used.
-T
C
ON
OXIC
LEARANCE
handled or been in c
handled or been in c
handled or been in con
handled or been in c
oduct t t t t has been dr
oduc
oduc
oduc
has been dr
has been dr
has been dr
has been drained o
ained of liquid and is saf
ained o
ained o
ained o
be ac
be ac
be acc c c c c epted f
epted f
epted for r
epted f
or repair
or r
or r
epair
epair
epair. . . . .
be ac
epted f
or r
epair
RMA #
xposed t
xposed t
o to o o o o xic or haz
o t
o t
xposed t
xposed to t
o t
ION A
ION A
ION A
ION A. If no
. If no
. If no, c , c , c , c , con
. If no
. If no
on
on
ontinue t
on
substances used wi
substanc
es used wi
es used with the r
es used wi
th the r
th the r
th the ref ef ef ef efer er er er erenc
es used wi
th the r
or all ma
or all ma
or all materials r
or all ma
terials ref ef ef ef efer er er er erenc
terials r
terials r
terials r
enced or list
enc
enc
enc
, pro o o o o vide an
, pr
, pr
, pr
vide an
vide an
vide any ac
vide an
y ac
y ac
y actions t
y ac
tions t
tions t
tions t
tions to be tak
oduct t t t t (e (e (e (e (ev v v v v en af
oduc
oduc
oduc
en after cleaning and/
en af
en af
en af
ter cleaning and/
ter cleaning and/
ter cleaning and/
ter cleaning and/or flushing).
ted, dr
ted, drained o
ted, dr
ted, dr
ained o
ained o
ained o
ained of liquid and is saf
f liquid and is safe t
f liquid and is saf
f liquid and is saf
f liquid and is saf
ontac
on
on
tact t t t t wi
tac
tac
wi
wi
with an
th an
th any t
th an
on
tac
wi
th an
f liquid and is saf
f liquid and is saf
f liquid and is safe t
f liquid and is saf
PHON
PHON
PHON
PHONE E E E E
PHON
Quantity
xic or haz
xic or hazar ar ar ar ardous ma
xic or haz
dous ma
dous ma
terials:
terials:
xic or haz
dous materials:
dous ma
terials:
terials:
tinue to SEC
tinue t
tinue t
tinue t
o SEC
o SEC
o SEC
o SECT T T T T ION B
ION B
ION B
ION B
ION B. . . . .
enc
enc
enced pr
ed produc
ed pr
ed pr
oduc
oduct(s
oduc
enc
ed pr
oduc
ed or list
ed or list
ed or list
ed or list pr pr pr pr precautions t
ecautions to be
ecautions t
ecautions t
ecautions t
o be taken in the e
o be tak
o be tak
o be tak
en in the e
en in the e
en in the ev v v v v en
en in the e
or flushing).
or flushing).
or flushing).
or flushing).
e t
e t
e t
e to handle
o handle
o handle
o handle
o handle. . . . .
Ini
Ini
Ini
Ini
Initial/Da
tial/Da
tial/Date te te te te
tial/Da
tial/Da
y to o o o o xic or haz
y t
y t
xic or haz
xic or haz
xic or hazar ar ar ar ardous
dous
dous
dous
y t
xic or haz
dous
e t
e t
e to handle
e t
o handle
o handle
o handle. . . . .
o handle
Ini
Ini
Initial/Da
Ini
Ini
tial/Date te te te te
tial/Da
tial/Da
tial/Da
P P P P P O O O O O SI SI SI SI SIT T T T T ION
ION
ION
ION
ION
1
t(s). ). ). ). ).
t(s
t(s
t(s
o be
o be
o be
o be
ent t t t t o o o o of f f f f
en
en
en
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