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RMA – REPAIR REQUEST FORM and DECLARATION OF DECONTAMINATION
Fill out and return to: E-mail
MACHINE / PRODUCT DATA
Type of machine / Model
Serial no.
purchase
document no.
Cause
Repair Warranty
Repair
Periodical maintenance
Description of defect
Blocked
Noisy
Motor failure
Other:
DECLARATION OF DECONTAMINATION
•
For the safety of our employees and compliance with the legal requirements during handling of substances hazardous to health
and the environment, this declaration must be filled out completely and sent for each machine / product.
•
Without said declaration filled out completely, repair cannot be carried out.
•
The declaration must be sent with the shipping documents.
1. The machine / the product
has NOT come into contact with hazardous substances. In case of repair / disposal, there is no risk to people and the
environment. Go to point 3.
has come into contact with hazardous substances. Go to point 2.
2.
Information on contamination
Type of system on which the machine is installed:
And it has come into contact with the following substances subject to the requirement of labelling or dangerous to health /
environment:
Trademark
Chemical name
Hazardous substance class
Characteristics (e.g. toxic,
flammable, corrosive)
The machine / product has been washed and cleaned on the outside. Specify the decontamination method used:
3.
Legally binding declaration
The undersigned hereby declares that the details given on this form are true and complete.
APPLICANT'S DETAILS
Company name:
Date
Street:
Postal
Code
City:
Province
Contact person:
E-mail / tel. no.
COMPLETION BY FPZ CUSTOMER CARE
RMA no.
NOTES
ENERGOEKONOM spol. s r.o., Wolkerova 433, CZ-250 82 Úvaly, Czech Republic, Tel.: +420 281 981 055, [email protected], www.energoekonom.cz
