33
Sample
3.Condition of the Vacuum Equipment and
Components
- Has the equipment been used ?
Yes
■
No
■
- What type of pump oil/liquid was used ?
- Is the equipment free from potentially
harmful substances ?
Yes
■
(go to Section 5)
No
■
(go to Section 4)
4.Process related Contamination of Vacuum
Equipment and Components
- toxic
Yes
■
No
■
- corrosive
Yes
■
No
■
- explosive
Yes
■
No
■
- biological hazard
Yes
■
No
■
- radioactive
Yes
■
No
■
- other harmful substances
Yes
■
No
■
Declaration of Contamination of Vacuum Equipment and Components
The repair and/or service of vacuum equipment and components will only be carried out if a correctly completed
declaration has been submitted. Non-completion will result in delay. The manufacturer could refuse to accept any
equipment without a declaration.
This declaration can only be completed and signed by authorised and qualified staff.
1.Description of Vacuum Equipment and
Components
- Equipment type/model :
- Code No :
- Serial No :
- Invoice No :
- Delivery Date :
2.Reason for Return
Vacuum equipment and components which have been contaminated by biological explosive or radioactive
substances, will not accepted without written evidence of decontamination.
Please list all substances, gases and by-products which may have come into contact with equipment :
Trade name
Chemical
Dangerous
Measures
First aid in
Product name
name
material
if spillage
case of
Manufacturer
(or symbol)
class
human contact
1.
2.
3.
4.
5.
5.Legally Binding Declaration
I hereby declare that the information supplied on this form is complete and accurate. The despatch of the contaminated
vacuum equipment and components will be in accordance with the appropriate regulations covering Packaging,
Transportation and Labelling of Dangerous Substances.
Name of organisation or compagny :
Address :
Post code :
Tel :
Fax :
Telex :
Name :
Job Title :
Date :
Compagny stamp :
Legally binding signature :
Copyright
c
by MaschinenbauVerlag GmbH, Lyoner Straße 18, 6000 Frankfurt/M. 71 Order No. : 2122
Copies : Page 1 (white) to manufacturer or representative -Page 2 (yellow) attach to consignment packaging securely - Page 3 (b
lue) copy for file of sender
