FORM F114A REV 6 - 10/22/2014
CLEAN EQUIPMENT FORM COMPANY NAME:
DATE:
NAME:
APPROVERS PHONE #:
EMAIL:
FAX:
PUMP IMFORMATION: MODEL #
SERIAL #
SIZE: MANUFACTURER:
REASON FOR REPAIR: THE OSHA CODE & EPA HAVE ESTABLISHED STRICT GUIDELINES FOR THE HANDLING OF A BROAD RANGE OF FLUIDS. WE ASK THAT ANY EQUIPMENT SENT TO US FOR INSPECTION AND/OR REPAIR BE PROPERLY DRAINED AND HAZARDOUS LIQUIDS NEUTRALIZED AT YOUR LOCATION TO PROTECT OUR EMPLOYEES AND THE ENVIRONMENT.
LIQUID THIS EQUIPMENT WAS HANDLING: DATE EQUIPMENT WAS DRAINED AND NEUTRALIZED: SIGNED: ______________________________________ PRINTED NAME: BEFORE EQUIPMENT CAN BE INSPECTED WE NEED: 1) THIS FORM COMPLETED AND SIGNED 2) PURCHASE ORDER TO INSPECT EQUIPMENT 3) COPY OF MSDS (MATERIAL SAFETY DATA SHEET) NOTE: NOT REQUIRED HANDLING CLEAN WATER
PLEASE RETURN TO REPAIR LOCATION:
UPON INSPECTION, YOU WILL RECEIVE A QUOTE FOR THE REPAIR WITH AN ESTIMATED LEAD TIME. WE WILL ADVISE A SCHEDULED REPAIR DATE ONCE YOUR PURCHASE ORDER IS RECEIVED. SHOULD YOU DECIDE NOT TO REPAIR, YOU WILL BE ADVISED THE AMOUNT OF THE EVALUATION FEE. YOU WILL ALSO NEED TO DECIDE IF YOU WANT US TO SCRAP THE ITEM OR RETURN TO YOU DISASSEMBLED. THANK YOU
Below for Tencarva Internal Use: Sales Engineer Name: S2K Standard Format Quote TAG # / SO # / PO #
REFERENCE INFO:
Specify level of Repair and Quote to furnish: Visual-only Inspection and Quote
Upgrade Repair Quote (for Tiers 1 and 2)