Declaration of harmlessness
71
© Lutz-Jesco GmbH 2014
Subject to technical changes.
140327
Solenoid-Diaphragm Dosing Pump
MAGDOS LP
Operating Instructions
BA-10231-02-V03
19 Declaration of harmlessness
Copy the Declaration of harmlessness and complete it separately for
each unit. Enclose one copy to the unit you are sending. Please send the
declaration of harmlessness to us also in advance per fax or e-mail!
Declaration of no objection
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: ......................................................................................................................................................................................
..................................................................................................................................................................................................................
..................................................................................................................................................................................................................
Dosing medium
Description: ..................................................................................
Irritating:
F
Yes
F
No
Properties: ....................................................................................
Corrosive:
F
Yes
F
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 the manufacturer finds 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:..........................................................................................
.....................................................................................................
Email:.......................................................................................
Customer No.:...............................................................................
Contact person: ........................................................................
Date, Signature:............................................................................