Chemtech Repair safety service form – Chemtech Scientific Incorporated

Repair Contact

Company Required Name Required Email Required Phone Required

Address Required City Required State Required Zip Required

Billing Same as Shipping

Billing Address

Address City State Zip Phone Fax

Product Information

Model Number Required Serial Number Required Gases and vapors that were pumped Required Brand of Oil in Pump Type of Process/ApplicationRequired Amount of Time Equipment was in use

Explanation of ProblemRequired

Explanation of Problem Please select at least one Seized Noisy Electrical Oil Leak Seal Leak Motor Problem Runs Hot Insufficient Vacuum Other

Warranty / Sales Status

Warranty / Sales Status Warranty
Non-Warranty
Demo Repair Return for credit

For Everyone's Safety Required

Poisonous Material Yes No

Carcinogen Yes No

Flammable Material Yes No

Biological Hazard Yes No

Mercury Yes No

Radioactive Material Yes No

Corrosive Material Yes No

Combustible Material Yes No

Oxidizer Yes No

Decontamination Procedure

for Direct & Belt Driven Pumps

1. Flush Pump Three Times. Drain pump completely. Refill with fresh vacuum oil. Operate pump blanked off for at least 15 minutes. Repeat all steps two more times. Drain completely. Oil should come out clean, otherwise repeat until clean.

2 Additional Cleaning Requirements:

Terms and Conditions

Legally Binding Declaration

I/we Hereby declare that the information supplied on this form is accurate and sufficient to judge any contamination level. I/we have read and agree to the Decontamination Procedure, and Terms and Conditions.

Name of Authorized Person Required Title Required Date Required

Safety Service Form