Please provide all pertinent information
Product Description
Product Number Quantity
The rThe r
The rThe r
The r
efef
efef
ef
erer
erer
er
enced prenced pr
enced prenced pr
enced pr
oducoduc
oducoduc
oduc
tt
tt
t
has been e has been e
has been e has been e
has been e
xposed to toxposed to to
xposed to toxposed to to
xposed to to
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:
YY
YY
Y
ES NOES NO
ES NOES NO
ES NO
If yIf y
If yIf y
If y
eses
eses
es
, c, c
, c, c
, c
omplete SECTomplete SECT
omplete SECTomplete SECT
omplete SECT
ION A. If noION A. If no
ION A. If noION A. If no
ION A. If no
, c, c
, c, c
, c
on
on
onon
on
tinue to SECTtinue to SECT
tinue to SECTtinue to SECT
tinue to SECT
ION BION B
ION BION B
ION B
..
..
.
APPLICATION
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/
substances used with the rsubstances used with the r
substances used with the rsubstances used with the r
substances used with the r
efef
efef
ef
erer
erer
er
enced prenced pr
enced prenced pr
enced 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 Safterial 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
enced or listenced or list
enced or listenced or list
enced or list
pr pr
pr pr
pr
ecautions to be takecautions to be tak
ecautions to be takecautions to be tak
ecautions to be tak
en 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
, pr
oo
oo
o
vide anvide an
vide anvide an
vide an
y acy ac
y acy ac
y ac
tions to be taktions to be tak
tions to be taktions to be tak
tions to 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
of human c of human c
of human c of human c
of human c
onon
onon
on
tactac
tactac
tac
tt
tt
t
with an with an
with an with an
with an
y liquid within the pry liquid within the pr
y liquid within the pry liquid within the pr
y liquid within the pr
oducoduc
oducoduc
oduc
tt
tt
t
(e (e
(e (e
(e
vv
vv
v
enen
enen
en
afaf
afaf
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, dr
ted, dr
ted, dr
ained 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 saf
e to handlee to handle
e to handlee to handle
e to handle
. P. P
. P. P
. P
rr
rr
r
oo
oo
o
vide decvide dec
vide decvide dec
vide dec
onon
onon
on
taminatamina
taminatamina
tamina
tion methodtion method
tion methodtion method
tion method
used.used.
used.used.
used.
S
ECTION
A: T
OXIC CLEARANCE
(To be completed if applied substances are hazardous)
Initial/DaInitial/Da
Initial/DaInitial/Da
Initial/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
with an with an
with an with an
with an
y toy to
y toy to
y to
xic or hazxic or haz
xic or hazxic or haz
xic or haz
arar
arar
ar
dous substances. dous substances.
dous substances. dous substances.
dous substances.
The prThe pr
The prThe pr
The pr
oducoduc
oducoduc
oduc
tt
tt
t
has been has been
has been has been
has been
drdr
drdr
dr
ained 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 saf
e to handle
e to handle
e to handlee to handle
e to handle
..
..
.
S
ECTION
B: NON-T
OXIC CLEARANCE
(To be completed if applied substances
arar
arar
ar
e note not
e note not
e not
hazardous)
Initial/DaInitial/Da
Initial/DaInitial/Da
Initial/Da
tete
tete
te
I herI her
I herI her
I her
eby declareby declar
eby declareby declar
eby declar
e thae tha
e thae tha
e tha
tt
tt
t
the c the c
the c the c
the c
onon
onon
on
tenten
tenten
ten
ts of this cts of this c
ts of this cts of this c
ts of this c
onsignmenonsignmen
onsignmenonsignmen
onsignmen
tt
tt
t
ar ar
ar ar
ar
e fully and accure fully and accur
e fully and accure fully and accur
e fully and accur
aa
aa
a
tely described abotely described abo
tely described abotely described abo
tely described abo
vv
vv
v
e by pre by pr
e by pre by pr
e by pr
oper shipping name and aroper shipping name and ar
oper shipping name and aroper shipping name and ar
oper shipping name and ar
ee
ee
e
classified, packclassified, pack
classified, packclassified, pack
classified, pack
ed, marked, mark
ed, marked, mark
ed, mark
ed and labeled, and ar
ed and labeled, and ar
ed and labeled, and ared and labeled, and ar
ed and labeled, and ar
e in all re in all r
e in all re in all r
e in all r
especespec
especespec
espec
ts in prts in pr
ts in prts in pr
ts in pr
oper coper c
oper coper c
oper c
ondition fondition f
ondition fondition f
ondition f
or tror tr
or tror tr
or tr
ansporanspor
ansporanspor
anspor
t, by all modest, by all modes
t, by all modest, by all modes
t, by all modes
, acc, acc
, acc, acc
, acc
oror
oror
or
ding to applicableding to applicable
ding to applicableding to applicable
ding to applicable
inin
inin
in
ternaterna
ternaterna
terna
tional and national and na
tional and national and na
tional and na
tional gotional go
tional gotional go
tional go
vv
vv
v
ernmenernmen
ernmenernmen
ernmen
tal rtal r
tal rtal r
tal r
egulaegula
egulaegula
egula
tions. Health and saftions. Health and saf
tions. Health and saftions. Health and saf
tions. Health and saf
ety issues arety issues ar
ety issues arety issues ar
ety issues ar
e 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 giv
enen
enen
en
cc
cc
c
onsideronsider
onsideronsider
onsider
aa
aa
a
tion during shipmention during shipmen
tion during shipmention during shipmen
tion during shipmen
tt
tt
t
. (A r. (A r
. (A r. (A r
. (A r
epair or inspecepair or inspec
epair or inspecepair or inspec
epair or inspec
tion of prtion of pr
tion of prtion of pr
tion of pr
oducoduc
oducoduc
oduc
tt
tt
t
will only be under will only be under
will only be under will only be under
will only be under
taktak
taktak
tak
en when this ceren when this cer
en when this ceren when this cer
en when this cer
tificatifica
tificatifica
tifica
te has been cte has been c
te has been cte has been c
te has been c
ompletedompleted
ompletedompleted
ompleted
and authorizand authoriz
and authoriz
and authoriz
and authoriz
ed 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 staf
f emplof emplo
f emplof emplo
f emplo
yy
yy
y
ed by the red by the r
ed by the red by the r
ed by the r
eturning ceturning c
eturning ceturning c
eturning c
ompanompan
ompanompan
ompan
yy
yy
y
.).)
.).)
.)
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 accepted f be accepted f
be accepted f be accepted f
be accepted f
or ror r
or ror r
or r
epairepair
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
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
SITSIT
SITSIT
SIT
IONION
IONION
ION
SIGNASIGNA
SIGNASIGNA
SIGNA
TT
TT
T
UU
UU
U
RR
RR
R
EE
EE
E
PHONPHON
PHONPHON
PHON
EE
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