Declaration of No Objection
59
© Lutz-Jesco GmbH 2014
Subject to technical changes.
140725
BA-10103-02-V01
Stepper Motor-driven Diaphragm Dosing Pump
MEMDOS SMART LK
Operating instructions
19 Declaration of No Objection
Please copy the declaration, stick it to the outside of the packaging and
return it with the device.
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:............................................................................
