Appendix
42/68-831-EN EBS852,
EBS862 (Contrac)
39
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Statement about the contamination of devices and components
The repair and/or maintenance of devices and components will only be performed when a completely filled out
explanation is present.
Otherwise, the shipment can be rejected. This explanation may only be filled out and signed by authorized
specialist personnel of the operator.
Customer details:
Company:
Address:
Contact person:
Telephone:
Fax: E-Mail:
Device details:
Type: Serial
no.:
Reason for the return/description of the defect:
Was this device used for working with substances which pose a threat or health risk?
F
Yes
F
No
If yes, which type of contamination (please place an X next to the applicable items)
biological
F
corrosive/irritating
F
combustible (highly/extremely combustible)
F
toxic
F
explosive
F
other harmful substances
F
radioactive
F
Which substances have had contact with the device?
1.
2.
3.
We hereby certify that the devices/parts shipped were cleaned and are free from any dangerous or poisonous
materials.
City, Date
Signature and company stamp
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