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Order No.:
Date of Purchase:
Company / Facility
Type No.:
Serial No.:
Street
Type:
Post Code / Town
1. Description of the fault:
:KLFKIDXOWRFFXUUHG"
2. Conditions of use:
D :HUHWKHSXPSVFRPSRQHQWVLQ
use
"
•
•
•
•
yes
•
•
•
•
no
E :KLFK
oil
ZDVXVHG"
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
F
Field of application
ORDGSURFHVVXVH
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
3. Type of contamination of pumps / components:
D WR[LF
1)
•
•
•
•
yes
•
•
•
•
no
E FRUURVLYH
1)
•
•
•
•
yes
•
•
•
•
no
F PLFURELRORJLFDO
1)
•
•
•
•
yes
•
•
•
•
no
G H[SORVLYH
1)
•
•
•
•
yes
•
•
•
•
no
H UDGLRDFWLYH
1)
•
•
•
•
yes
•
•
•
•
no
I RWKHUKDUPIXOVXEVWDQFHV
1)
•
•
•
•
yes
•
•
•
•
no
* In the case of rotary vane pumps
and roots pumps (Important!)
**
Pumps / components will only be accepted if proof is provided that they have been properly cleaned.
By arrangement, cleaning can be done by
//*
*PE+
.
Type(s) of substances or process-related reaction products which came into contact with the pumps/ components:
KL
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Danger class
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Are the pumps / components free of harmful substances?
•
•
•
•
yes
•
•
•
•
no
4. Legally binding declaration:
,:HGHFODUHWKDWWKHVWDWHPHQWVKHUHDUHFRUUHFWDQGFRPSOHWH
7KHSXPSVFRPSRQHQWVDUHVKLSSHGLQDFFRUGDQFHZLWKWKHOHJDOUHTXLHUHE\ZHRUGHUWKHUHSDLU
&RQWDFW
BBBBBBBBBBBBBBBB
3KRQH
BBBBBBBBBBBBBBBBBB
'HSDUWPHQW
BBBBBBBBBBBBBBBB
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BBBBBBBBBBBBBBBBBB
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BBBBBBBBBBBBBBBB
Legally binding signature:
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Company Stamp:
7KHUHSDLUFDQRQO\EHPDGHLIDFRPSOHWHO\ILOOHGRXWGDPDJHUHSRUWLVUHFHLYHG2WKHUZLVHWKHZRUNPD\EHGHOD\HG2XUJHQHUDOWHUPVRIGHOLYHU\
DQGSD\PHQWDSSO\
1)
Answer all questions or mark with
•
•
•
•
yes
or
•
•
•
•
no
. If a box is not filled out, we automatically suppose that there was a contamination and
the required measures are charged to you.
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