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130000761_002_A0 - 08/2008 - © Oerlikon Leybold Vacuum
Declaration of Contamination of Compressors, Vacuum Pumps and Components
The repair and / or servicing of compressors, vacuum pumps and components will be carried out only if a correctly completed declaration has been sub-
mitted.
Non-completion will result in delay
. The manufacturer can refuse to accept any equipment without a declaration.
A separate declaration has to be completed for each single component.
This declaration may be completed and signed only by authorised and qualified staff.
Customer/Dep./Institute: ________________________________
___________________________________________________
Address
___________________________________________
___________________________________________
Person to contact:
___________________________________
Phone:
__________________ Fax: __________________
End user:
__________________________________________
Reason for return
!
!
applicable please mark
"
Repair
"
chargeable
"
warranty
"
Exchange
"
chargeable
"
warranty
"
exchange already arranged / received
Return only:
"
rent
"
loan
"
for credit
Calibration:
"
DKD
"
Factory calibration
"
Quality test certificate DIN 55350-18-4.2.1
A. Description of the Leybold product
Failure description:
___________________________________
Material description: _____________________________________
___________________________________________________
Catalog number:
_______________________________________
Additional parts:
_____________________________________
Serial number:
_______________________________________
Application Tool: _____________________________________
Type of oil (Forevacuum pumps): ____________________________
Application Process:
__________________________________
B. Condition of the equipment
No
1)
Yes
No
Contamination:
No
1)
Yes
1. Has the equipment been used
1)
"
"
toxic
"
"
2. Drained (Product/service fluid)
"
"
corrosive
"
"
3. All openings sealed airtight
"
flammable
"
"
4. Purged
"
"
explosive
2)
"
"
If yes which cleaning agent:
_______________________________________
radioactive
2)
"
"
and which method of cleaning:
_______________________________________
microbiological
2)
"
"
1)
if answered with “No” go to
D
.
other harmful substances
"
"
C. Description of processed substances (Please fill in absolutely)
1. What substances have come into contact with the equipment:
Trade name and / or chemical term of service fluids and substances processed, properties of the substances; According to safety data sheet
(e.g. toxic, inflammable, corrosive, radioactive)
Tradename:
Chemical name:
a) ______________________________________________________________________________________________________
b) ______________________________________________________________________________________________________
c) ______________________________________________________________________________________________________
d) ______________________________________________________________________________________________________
No
Yes
2. Are these substances harmful?
"
"
3. Dangerous decomposition products when heated?
"
"
If yes, which? ___________________________________________________________________________________________
2)
Components contaminated by microbiological, explosive or radioactive products/substances will not be accepted
without written evidence of decontamination.
D. Legally binding declaration
I / we hereby declare that the information supplied on this form is accurate and sufficient to judge any contamination level.
Name of authorised person (block letters):
____________________________
Date _____________ Signatur of authorised person ___________________________
firm stamp
17200001_002_00 © Oerlikon Leybold Vacuum
