Declaration of Contamination
Address: Industriestr. 1, D-53819 Neunkirchen-Seelscheid Dokument Nr. F-KE-01-090211-303
Phone: +49 (0) 2247 702-0,
Fax: +49 (0) 2247 702-44
Email: [email protected], www.homa-pumpen.de
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:
__________________
corrosive no
□
yes
□
which substance:
__________________
microbiological no
□
yes
□
which substance:
__________________
explosive no
□
yes
□
which substance:
__________________
radioactive no
□
yes
□
which substance:
__________________
other substances
no
□
yes
□
which 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 dangerous quantities.
Company:
Street:
Zip code, City:
Contact person:
Phone:
Fax:
e-mail:
Date
Company
stamp
and
signature
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