Declaration of harmlessness
33
© Lutz-Jesco GmbH 2016
Subject to technical changes.
160426
Vacuum Regulator for Chlorine Gas
C 2700-V
Operating Instructions
BA-21210-02-V05
14 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 Decla-
ration of Conformity 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:............................................................................
