Homa AM***-C, Instruction Manual

Page: 69 / 72

69
12. Declaration of Contamination
The repair if the instruments can only be accomplished if this document is filled out completely and accurately.
ANSWER by FAX: HOMA Pumpenfabrik GmbH:… +49 (0) 2247 702 - 44
Pump data:
Type:
Part No:
Serial no:
Reason for return:
Contamination of the instruments:
toxic no □ yes □ substance:
corrosive no □ yes □ substance:
microbiological no □ yes □ substance:
explosive no □ yes □ substance:
radioactive no □ yes □ substance:
other substances no □ yes □ substance:
Legally binding declaration:
We hereby certify that the returned parts have been cleaned carefully. To the best of our knowledge, they are free from any residues in dange-
rous quantities.
Company:
Street: Zip code, City:
Contact person:
Phone: Fax:
e-mail:
Date Company stamp and signature