* Date:
Day
Month
Year
Contact Information
* Contact Name:
Title:
* Company Name:
* Address #1:
Address #2:
* City:
State/Prov.:
* Zip/Postal Code:
Country:
* Phone Number:
Fax Number:
* E-mail Address:
*
Vessel size
:
* Jacketed:
YES
NO
* Mfg. No:
*
Drive Size
:
* Model No:
*Serial No:
*
Accessory Part No.:
* Description:
*Has the equipment been cleaned per the procedures outlined?
YES
NO
* If NO, please give the reason(s) why:
*Does the equipment have a hole through the liner into the jacket chamber?
YES
NO
*Which materials were used in the equipment during last production sequence?
Hazardous
Toxic
Explosive
Flammable
Irritating Chemicals
On Vessel:
YES
NO
On Jacket:
YES
NO
What were these chemicals and what precautions should be taken for each?
Vessel:
Jacket:
*Would heat from a cutting torch cause these chemicals to produce toxic/irritating substances or an explosion?
YES
NO
*Please provide the name and phone number of the individual in your organization who is most familiar with the chemicals most recently used in this vessel and who can be contacted in the event of a medical or other emergency.
*Name:
*Phone:
*Title:
*Fax No:
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