Repair / Rebuild Request Form

First Name

Last Name

Phone

Company

Address Line 1

Address Line 2

City

State

Postal Code

How would you prefer to be contacted?

Phone

Repair Product Details

Please fill out this section to the best of your ability.

Manufacturer

Model #

Item # / Part #

Serial #

Other Identifying Information

Please describe the issues you are experiencing with the pump / product:

DECONTAMINATION

Please fill out this section in it's entirety. Failure to complete and submit this form before a repair arrives on our dock will result in a refusal of delivery/return to sender.

What materials was the pump / product used with? (list all materials that came into contact with the pump / product)

What is used to clean up this material? (e.g. soap & water, paint thinner, isopropyl alcohol, etc.)

Special instruction for method of cleaning this material:

Instructions for cleaning and disposal: (eg wear rubber gloves, eye protection, respirator, etc.)

Actions to be taken in the event of human contact with material or cleaning fluids: (e.g. rinse with water, call poison control or immediately dial 911, etc.)

Upload any MSDS or other material information you have available:

NOTE: IF UNIT IS RECEIVED AND DEEMED UNSUITABLE FOR HANDLING, IT WILL BE RETURN TO CUSTOMER. ALL SHIPPING AND HANDLING CHARGES WILL BE THE CUSTOMER'S RESPONSIBILITY, AS WELL AS ANY LABOR COSTS INCURRED BY SPRINGER PUMPS, LLC.

In compliance with Springer Pumps, LLC health and safety procedures, all persons wishing to return or submit for repair any product to Springer Pumps, LLC are required to declare any and all substances which have been in contact with said product. An RGA # will not be issued until this completed form is received at Springer Pumps, LLC and the product is approved for return. Please complete a separate form for each individual product to be returned. Any necessary product decontamination and/or cleaning shall be the responsibility of the customer prior to the return.

I HEREBY CONFIRM THAT THE INFORMATION SUPPLIED HEREIN IS ACCURATE AND COMPLETE. THE PRODUCT BEING RETURNED HAS BEEN DECONTAMINATED AND CLEANED AND IS SAFE FOR HANDLING.

I agree to the above statement

Do not ship or deliver to us without an RGA#, which we will issue once we receive the above info.

Contact Information