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9 Shutdown, storage, transport and disposal

R II Operation Manual, Version E

9 .3

Health and safety clearance form

Declaration concerning safety, potential hazards and safe disposal of waste, e .g . used oil .

Safety and health of our staff, laws and regulations regarding the handling of dangerous goods, occupational health and
safety regulations, safety at work laws and regulations regarding safe disposal of waste, e.g. waste oil, require that for all
Rotavapors and other products this form must be send to our office duly completed and signed before any equipment is
repaired or dispatched or to our premises.

Products will not be accepted for any procedure and handling and repair/DKD calibration will not start before
we have received this declaration .

a) Fax or post a

completed copy of this form

to us in advance. The declaration must arrive before the equipment.

Enclose a second, completed copy with the product .

If the product is contaminated you must notify the carrier

(GGVE, GGVS, RID, ADR)

b) Inevitably, the repair process will be delayed considerably, if this information is missing or this procedure is not obeyed. We

hope for your understanding for these measures which are beyond our control and that you will assist us in expediting the
repair procedure.

Make sure that you know all about the substances which have been in contact with the equipment and that
all questions have been answered correctly and in detail .

1 . Product (Model): . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2 . Serial No .: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3 . List of substances in contact with the

equipment or reaction products:

3 .1 Chemical/substance name, chemical

symbol:

a) .........................................................................
b) .........................................................................
c) .........................................................................
d) .........................................................................

3 .2 Important information and precautions,

e .g . danger classification

4 . Declaration (please mark as applicable):

4 .1 for non dangerous goods:

We assure for the returned product that
- neither toxic, corrosive, bilogically active, explosive,

radioactive nor contamination dangerous in any way has
occurred.

- the product is free of dangerous substances.
The oil or residues of pumped media have been drained.

4 .2 for dangerous goods:

We assure for the returned product that
- all substances, toxic, corrosive, biologically active,
explosive, radioactive or dangerous in any way which have
pumped or been in contact with the product are listed in 3.1,
that the information is complete and that we have not with-
held any information.
- the product, in accordance with regulations, has been

cleaned

decontaminated

sterilized

5 . Way of transport/carrier:

.............................................................................
Day of dispatch to BÜCHI Labortechnik AG:
.............................................................................

We declare that the following measures -
where applicable - have been taken:

- The oil has been drained from the product.

Important: Dispose of according to national
regulations .

- The interior of the product has been cleaned.
- All inlet and outlet ports of the product have been sealed.
- The product has been properly packed, if necessary,

please order an original packaging (costs will be charged)
and marked as appropriate.

- The carrier has been informed about the hazardous nature

of goods (if applicable).

Signature: ...............................................................................

Name (print): ...........................................................................

Job title (print): ........................................................................

Company’s seal: .....................................................................

Date: .......................................................................................