P/SF/Konta
XIV
RA No.
Declaration of Hazardous Material and De-Contamination
Please reference the Return Authorization Number (RA#), obtained from Hauser, on all paperwork and
mark the RA# clearly on the outside of the box. If this procedure is not followed, it may result in the refusal of the
package at our facility.
Because of legal regulations and for the safety of our employees and operating equipment, we need the "Declaration of Hazardous Material
and De-Contamination", with your signature, before your order can be handled. Please make absolutely sure to attach it to the outside of the
packaging.
Serial number
________________________
Type of instrument / sensor
____________________________________________
Used as SIL device in a Safety Instrumented System
Process data
Temperature
_____ [°F]
[°C]
Conductivity
________
_____
[µS/cm]
Pressure
_____ [psi]
[ Pa ]
Viscosity
_____ [cp]
[mm /s]
_____
_____
2
Medium and warnings
corrosive
harmless
other *
toxic
Identification
CAS No.
flammable
harmful/
irritant
Medium /concentration
Process
medium
Medium for
process cleaning
Returned part
cleaned with
* explosive; oxidising; dangerous for the environment; biological risk; radioactive
Please tick should one of the above be applicable, include safety data sheet and, if necessary, special handling instructions.
Description of failure
_
_______________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
Company data
Company
________________________________
_________________________________________________
Address
_________________________________________________
_________________________________________________
___
Phone number of contact person
____________________________________________
Fax / E-Mail ____________________________________________
Your order No. ____________________________
“We hereby certify that this declaration is filled out truthfully and completely to the best of our knowledge.We further certify that the returned
parts have been carefully cleaned. To the best of our knowledge they are free of any residues in dangerous quantities.”
(
place, date)
Name, dept.
(please print)
Signature
