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G 200
F 00956 - Edition 09 - May 12
Declaration of contamination
This questionnaire can be downloaded from: www.adixen.com
Repair and/or maintenance will be carried out on vacuum equipment or components only if a fully completed, correct declaration
of contamination is provided. If it is not the case, the corresponding repair will be delayed or omitted. A separate declaration must
be submitted for each device or each component.
1. EQUIPEMENT
3. EQUIPMENT CONDITION
If «yes», sealed package and specific label are required
1.
2.
3.
4.
yes
2. REASON FOR RETURN - SERVICE REQUIRED (mandatory)
Toxic
Carcinogenic
Combustible
Corrosive
Explosive
Biological*
Radioactive*
This declaration can only be completed and signed by an authorised and qualified person.
Has the equipment been used ?
no
Has the equipment been cleaned?
Is the equipment free from potential harmfull substances ?
yes
no
no
yes
4. COPPER PROCESS
Has the equipment been used
on a Copper process ?
yes
no
5.1 PROCESS RELATED CONTAMINATION Chimique
(*) The equipment will be accepted only with a written decontamination
certificate
no
yes
yes
yes
no
no
no
yes
no
yes
no
yes
no
yes
Chemical name
(or symbol)
Risks and precautions associated with substances
Process description
Country:
Last Name:
First name:
Function:
Name of the company / organization:
Address:
City:
State:
Post Code:
Phone number:
E-mail address:
Signature and company seal:
6. Legally binding declaration
5.2 Process and list of hazardous substances or by-products which may have come into contact with the equipment :
Description:
Reference (P/N):
Serial N°:
Type of pump oil used :
Return N°:
Under warranty
Out of warranty
Cleaning detergent /method:
Others
We hereby guarantee that the information in this declaration is correct and complete. I, undersigned, am able to provide a true
assessment. We are aware of our liability toward the contractor for damage resulting from incomplete or inaccurate details; we
undertake to be responsible for any third-party claims based upon claims of contamination or other nonconformity with the
statements herein.
Date:
Albanie
06/06/12
adixen Vacuum Products - Operating instructions - ATH500 M-MT
