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Health and Safety Clearance
Declaration concerning safety, potential hazards and safe disposal of waste.
For the safety and health of our staff, laws and regulations regarding the handling of
dangerous goods, occupational health and safety regulations, safety at work laws and
regulations regarding safe disposal of waste, e.g. chemical waste, chemical residue or
solvent, require that this form must be duly completed and signed when equipment or
defective parts were delivered to our premises.
Instruments or parts will not be accepted if this declaration is not present.
Equipment
Model:
1.A Declaration for non dangerous goods
We assure that the returned equipment
has not been used in the laboratory and is new
was not in contact with toxic, corrosive, biologically active, explosive, radioactive or
other dangerous matters.
is free of contamination. The solvents or residues of pumped media have been
drained.
1.B Declaration for dangerous goods
List of dangerous substances in contact with the equipment:
Chemical, substance
We assure for the returned equipment that
all substances, toxic, corrosive, biologically active, explosive, radioactive or
dangerous in any way which have pumped or been in contact with the equipment
are listed above.
the equipment has been cleaned, decontaminated, sterilized inside and outside and
all inlet and outlet ports of the equipment have been sealed.
2. Final Declaration
We hereby declare that
-
we know all about the substances which have been in contact with the equipment
and all questions have been answered correctly
-
we have taken all measures to prevent any potential risks with the delivered
equipment.
Company name or stamp:
Place, date:
Name (print), job title (print):
Signature:
Health and Safety Clearance_20081110.doc_20081110
Part/Instrument no.:
Danger classification
Version 1.0
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