65
Contact your local distributor for return authorization.
15. Declaration of harmlessness
*) Please delete as applicable!
Please, return declaration with product
Lutz-Jesco GmbH, Am Bostelberge 19
by attaching to the package.
D-30900 Wedemark, Germany
Declaration of harmlessness
(Please fill in separately for each unit – pump or accessory –)
We forward the following metering equipment to you for repair:
Type (metering pump or accessory):
Part No.:
Order No.:
Date of delivery:
Reason for repair:
Chemical
metered:
Properties: Irritating: Yes/No
Corrosive: Yes/No
We hereby certify, that the product has been cleaned thoroughly inside and outside before returning,
that it is free from hazardous material (i.e.
chemical
,
biological
,
toxic
,
flammable
,
and
radioactive
material) and that the lubricant has been drained.*)
If Lutz-Jesco has to (further) clean the unit the costs will be charged 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:
Date
Signature / Stamp
