Safety Questionnaire

1COMPANY


Company name
Contact name
(who has filled in questionnaire)
Position
Tel. no
Fax no
E-mail

2EQUIPMENT


Equipment description
Part number
Serial no
Type of process
 
Shipping date (dd/mm/yy)

3SERVICE


Service required
Type of anomaly observed

4COPPER PROCESS


Product used on a Copper process yes no

4SAFETY ASPECT


The equipment has been in contact with the following substances :
(name and chemical formula)

These substances present the following risks


Chemical  
Toxic yes no
Carcinogenic yes no
Combustible yes no
Corrosive yes no
Explosive yes no
Biological yes no
Radioactive yes no
Other

Detailed explanation

5SIGNATURE


You have replied "Yes" to one of the above questions
I confirm that only the substances mentioned have been in contact with the above equipment and that the preparation, packing and transport procedures have been complied with.
The product requires protection at the inlet and exhaust

You have replied "No" to all the above questions
I confirm that the above equipment has not been in contact with any dangerous substance and that the preparation, packing and transport procedures have been complied with.
This product is without risk

Name
Position
Date
 

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