SAFETY SHEET
42
520978-00
A
NN
EX
A vacuum pump and its accessories may in some cases draw up or be in contact with hazardous substances. For reasons of
safety of the staff or our after sales and repair departments, and in accordance with the regulations,
it is mandatory that you
complete this form with the following essential information when returning the equipment to the factory for repair
.
Otherwise, the products received will be isolated in a quarantine area and no human intervention may be undertaken.
Machine type:
....................................................................................................................................................
Serial number:
....................................................................................................................................................
Date of sending:
....................................................................................................................................................
Reason for return:
....................................................................................................................................................
ESSENTIAL INFORMATION
What type of oil is used for the pump
: ...............................................................................................................................
Presence of bacteriological filtration:
YES
NO
Presence of bacteriological cartridge:
YES
NO
Does the device contain toxic substances:
YES
NO
Does the device contain corrosive substances:
YES
NO
Does the device contain CMR* substances:
YES
NO
Does the device contain explosive substances:
YES
NO
Does the device contain radioactive substances:
YES
NO
Others: ........................................................................
YES
NO
(*) CMR : carcinogenic - mutagenic - reprotoxic
S If radioactive or explosive materials are present, list the substances of the gas and the by-products:
Product name
Chemical composition
Risk category
First aid
Legal declaration
We declare on our honour that the data in this declaration was provided exhaustively, sincerely and factually and that the
undersigned is qualified to judge this. We are aware that we are liable in relation to the contractor for incomplete or
incorrect data. We commit ourselves to exempt the contractor from any responsibility in relation to third parties in respect
of damage and interests owed to incomplete or incorrect data. We are aware that beyond this declaration, our responsibility
is directly engaged in relation to third parties, which includes in particular the employees of the contractor responsible for
handling/repairing the product.
Company: ..............................................................................
Postal code / city: ...............................................................
Street: ....................................................................................
Fax: .....................................................................................
Name (in capital letters): .......................................................
Position: ..............................................................................
Phone: ...................................................................................
Company seal: ....................................................................
Date: ......................................................................................
Signature:
