Declaration of harmlessness
Please copy and send with and fill out for each device!
Declaration of harmlessness
(please fill out a separate form for each appliance)
We forward the following device for repairs:
Device and device type: .............................................................................................................
Part-no.: ...................................................................................................................................
Order No.: ................................................................................................................................
Date of delivery: ........................................................................................................................
Reason for repair: .....................................................................................................................
Chemical metered:
Description ................................................................................................................................
Properties: .................................................................................................................................
Irritating:
Yes/No*)
Corrosive: Yes/No*)
*) If not applicable please cross out!
We hereby certify, that the product has been cleaned thourohly inside and outside before returning,
that it is fee from hazardous material (i.e. chemical, biological, toxic, flammable, and radioactive mate-
rial) and that the lubricant has been drained. *)
If the manufacturer find it necessary to carry out further cleaning work, we accept the charge will be
made to us.
We assure that the aforementioned information is correct and complete and that the unit is dispatched
according to the legal requirements.
Company: ..................................................................................................................................
Address: ....................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................
Phone: ......................................................................................................................................
Fax: ...........................................................................................................................................
E-Mail: ......................................................................................................................................
Customer No.: ...........................................................................................................................
Contact person: .........................................................................................................................
Date, Signature ..........................................................................................................................
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| Operation & Maintenance Instructions | Declaration of harmlessness
