Chell Request form

COSHH FORM

Customer Details

Equipment details (please complete one form per instrument)

Equipment Type

Serial Number

Is the Equipment Faulty?

Yes

Service Required (* indicates E.R.A. number required, Please phone our Service Manager on 01692 500555 for details).

Panic*	Priority*	Standard
E.R.A. Number
Purchase Order Number
Maximum Value (not to be exceeded without recourse)

Calibration Requirement

6 point calibration	Single Calibration, no adjustments made
11 point calibration	Single Calibration, after returning to Manufacturer's specification
	Double Calibration, both before and after any required adjustments
Special	We will call you to discuss your precise requirements

COSHH Regulations Substances Hazardous to Health

In view of the toxic/hazardous nature of some of the gases and vapours handled by the equipment we sell, a statement will be required from the user advising us that the equipment returned is now safe to work on. Any equipment arriving at Chell which has no COSHH statement will be double bagged and placed in external stores until a suitable statement has been obtained. You will understand, of course, that these requirements are not only in the interest of the continuing good health of our employees but also that of yours and your carriers. It is also required in order to comply with the Health and Safety at Work Act and others.
Are these substances hazardous to health? YES NO	Please state with what substances this equipment has been in contact.
I declare this equipment has been purged/cleaned and is safe to handle.
Name Position	Declaration Date