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9. 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 □
which substance:
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corrosive
no □ yes □
which substance:
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microbiological
no □ yes □
which substance:
__________________
explosive
no □ yes □
which substance:
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radioactive
no □ yes □
which substance:
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other substances
no □ yes □
which substance:
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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 dangerous quantities.
Company:
Street:
Zip code, City:
Contact person:
Phone:
Fax:
e-mail:
Date
Company stamp and signature
Summary of Contents for H832-15/0,37W
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