Please provide all pertinent information
Product Description
Product Number Quantity
The rThe r
The rThe r
The refef
efef
eferer
erer
erenced prenced pr
enced prenced pr
enced producoduc
oducoduc
oductt
tt
thas been ehas been e
has been ehas been e
has been exposed to toxposed to to
xposed to toxposed to to
xposed to toxic or hazxic or haz
xic or hazxic or haz
xic or hazarar
arar
ardous madous ma
dous madous ma
dous materials:terials:
terials:terials:
terials: YY
YY
YES NOES NO
ES NOES NO
ES NO
If yIf y
If yIf y
If yeses
eses
es, c, c
, c, c
, complete SECTomplete SECT
omplete SECTomplete SECT
omplete SECTION A. If noION A. If no
ION A. If noION A. If no
ION A. If no, c, c
, c, c
, con
on
onon
ontinue to SECTtinue to SECT
tinue to SECTtinue to SECT
tinue to SECTION BION B
ION BION B
ION B.....
APPLICATION
PP
PP
Please speciflease specif
lease speciflease specif
lease specify all hazy all haz
y all hazy all haz
y all hazarar
arar
ardous madous ma
dous madous ma
dous materials/terials/
terials/terials/
terials/substances used with the rsubstances used with the r
substances used with the rsubstances used with the r
substances used with the refef
efef
eferer
erer
erenced prenced pr
enced prenced pr
enced producoduc
oducoduc
oduct(st(s
t(st(s
t(s).).
).).
).
PP
PP
Prr
rr
roo
oo
ovide the Mavide the Ma
vide the Mavide the Ma
vide the Material Safterial Saf
terial Safterial Saf
terial Safety Daety Da
ety Daety Da
ety Data Sheetta Sheet
ta Sheetta Sheet
ta Sheet f
f
ff
for all maor all ma
or all maor all ma
or all materials rterials r
terials rterials r
terials refef
efef
eferer
erer
erenced or listenced or list
enced or listenced or list
enced or list prpr
prpr
precautions to be takecautions to be tak
ecautions to be takecautions to be tak
ecautions to be taken when handling theseen when handling these
en when handling theseen when handling these
en when handling these
substances. Alsosubstances. Also
substances. Alsosubstances. Also
substances. Also, pr, pr
, pr, pr
, proo
oo
ovide anvide an
vide anvide an
vide any acy ac
y acy ac
y actions to be taktions to be tak
tions to be taktions to be tak
tions to be taken in the een in the e
en in the een in the e
en in the evv
vv
venen
enen
entt
tt
tof human cof human c
of human cof human c
of human conon
onon
ontactac
tactac
tactt
tt
twith anwith an
with anwith an
with any liquid within the pry liquid within the pr
y liquid within the pry liquid within the pr
y liquid within the producoduc
oducoduc
oductt
tt
t(e(e
(e(e
(evv
vv
venen
enen
en
afaf
afaf
after 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 producoduc
oducoduc
oductt
tt
trr
rr
returned has been deceturned has been dec
eturned has been deceturned has been dec
eturned has been deconon
onon
ontaminatamina
taminatamina
taminated, drted, dr
ted, dr
ted, dr
ted, drained of liquid and is safained of liquid and is saf
ained of liquid and is safained of liquid and is saf
ained of liquid and is safe to handlee to handle
e to handlee to handle
e to handle. P. P
. P. P
. Prr
rr
roo
oo
ovide decvide dec
vide decvide dec
vide deconon
onon
ontaminatamina
taminatamina
tamination methodtion method
tion methodtion method
tion method
used.used.
used.used.
used.
SECTION A: TOXIC CLEARANCE
(To be completed if applied substances are hazardous)
Initial/DaInitial/Da
Initial/DaInitial/Da
Initial/Datete
tete
te
The prThe pr
The prThe pr
The producoduc
oducoduc
oductt
tt
trr
rr
returned has noteturned has not
eturned has noteturned has not
eturned has not handled or been in chandled or been in c
handled or been in chandled or been in c
handled or been in conon
onon
ontactac
tactac
tactt
tt
twith anwith an
with anwith an
with any toy to
y toy to
y toxic or hazxic or haz
xic or hazxic or haz
xic or hazarar
arar
ardous substances.dous substances.
dous substances.dous substances.
dous substances. The prThe pr
The prThe pr
The producoduc
oducoduc
oductt
tt
thas beenhas been
has beenhas been
has been
drdr
drdr
drained of liquid and is safained of liquid and is saf
ained of liquid and is safained of liquid and is saf
ained of liquid and is safe to handle
e to handle
e to handlee to handle
e to handle.....
SECTION B: NON-TOXIC CLEARANCE
(To be completed if applied substances arar
arar
are note not
e note not
e not hazardous)
Initial/DaInitial/Da
Initial/DaInitial/Da
Initial/Datete
tete
te
I herI her
I herI her
I hereby declareby declar
eby declareby declar
eby declare thae tha
e thae tha
e thatt
tt
tthe cthe c
the cthe c
the conon
onon
ontenten
tenten
tents of this cts of this c
ts of this cts of this c
ts of this consignmenonsignmen
onsignmenonsignmen
onsignmentt
tt
tarar
arar
are fully and accure fully and accur
e fully and accure fully and accur
e fully and accuraa
aa
ately described abotely described abo
tely described abotely described abo
tely described abovv
vv
ve by pre by pr
e by pre by pr
e by proper shipping name and aroper shipping name and ar
oper shipping name and aroper shipping name and ar
oper shipping name and aree
ee
e
classified, packclassified, pack
classified, packclassified, pack
classified, packed, marked, mark
ed, marked, mark
ed, marked and labeled, and ar
ed and labeled, and ar
ed and labeled, and ared and labeled, and ar
ed and labeled, and are in all re in all r
e in all re in all r
e in all respecespec
especespec
espects in prts in pr
ts in prts in pr
ts in proper coper c
oper coper c
oper condition fondition f
ondition fondition f
ondition for tror tr
or tror tr
or transporanspor
ansporanspor
ansport, by all modest, by all modes
t, by all modest, by all modes
t, by all modes, acc, acc
, acc, acc
, accoror
oror
ording to applicableding to applicable
ding to applicableding to applicable
ding to applicable
inin
inin
internaterna
ternaterna
ternational and national and na
tional and national and na
tional and national gotional go
tional gotional go
tional govv
vv
vernmenernmen
ernmenernmen
ernmental rtal r
tal rtal r
tal regulaegula
egulaegula
egulations. Health and saftions. Health and saf
tions. Health and saftions. Health and saf
tions. Health and safety issues arety issues ar
ety issues arety issues ar
ety issues are clearly understood and will be give clearly understood and will be giv
e clearly understood and will be give clearly understood and will be giv
e clearly understood and will be givenen
enen
en
cc
cc
consideronsider
onsideronsider
onsideraa
aa
ation during shipmention during shipmen
tion during shipmention during shipmen
tion during shipmentt
tt
t. (A r. (A r
. (A r. (A r
. (A repair or inspecepair or inspec
epair or inspecepair or inspec
epair or inspection of prtion of pr
tion of prtion of pr
tion of producoduc
oducoduc
oductt
tt
twill only be underwill only be under
will only be underwill only be under
will only be undertaktak
taktak
taken when this ceren when this cer
en when this ceren when this cer
en when this certificatifica
tificatifica
tificate has been cte has been c
te has been cte has been c
te has been completedompleted
ompletedompleted
ompleted
and authorizand authoriz
and authoriz
and authoriz
and authorized by a qualified member of stafed by a qualified member of staf
ed by a qualified member of stafed by a qualified member of staf
ed by a qualified member of staff emplof emplo
f emplof emplo
f employy
yy
yed by the red by the r
ed by the red by the r
ed by the returning ceturning c
eturning ceturning c
eturning companompan
ompanompan
ompanyy
yy
y.).)
.).)
.)
RR
RR
Radioacadioac
adioacadioac
adioactivtiv
tivtiv
tive pre pr
e pre pr
e producoduc
oducoduc
oducts will notts will not
ts will notts will not
ts will not be accepted fbe accepted f
be accepted fbe accepted f
be accepted for ror r
or ror r
or repairepair
epairepair
epair..
..
. 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.
CC
CC
COO
OO
OMPMP
MPMP
MPANAN
ANAN
ANYY
YY
Y
NANA
NANA
NAMEME
MEME
ME
NANA
NANA
NAMEME
MEME
ME PP
PP
POO
OO
OSITSIT
SITSIT
SITIONION
IONION
ION
SIGNASIGNA
SIGNASIGNA
SIGNATT
TT
TUU
UU
URR
RR
REE
EE
EPHONPHON
PHONPHON
PHONEE
EE
E
GRUNDFOS
Certificate of Cleanliness
Health and Safety Clearance Form
Grundfos Pumps Corporation
17100 W. 118th Terrace
Olathe, Kansas 66062
Telephone: 913.227.3400
Fax: 913.227.3500
www.grundfos.com
L-QC-FRM-002 Rev. 08/03
PRINTED IN USA