32
BG 805 204 BE / B (0203) QMS200.oi
Declaration of Contamination
Legally binding declaration:
We hereby declare that the information on this form is complete and accurate and that we will assume any further costs that may
arise. The contaminated product will be dispatched in accordance with the applicable regulations.
Organization/company
Address
Post code, place
Phone
Fax
Name
Date and legally binding signature
Company stamp
1) or not containing any amount
of hazardous residues that
exceed the permissible ex-
posure limits
!
!
!
!
Process related contamination of product
toxic
no
!
1)
yes
!
caustic
no
!
1)
yes
!
biological hazard
no
!
yes
!
2)
explosive
no
!
yes
!
2)
radioactive
no
!
yes
!
2)
other harmful substances no
!
1)
yes
!
The service, repair, and/or disposal of vacuum equipment and components will only be carried out if a correctly completed declaration has
been submitted. Non-completion will result in delay.
This declaration may only be completed (in block letters) and signed by authorized and qualified staff.
Copies:
Original for addressee - 1 copy for accompanying documents - 1 copy for file of sender
!!
!
!!
!
!!
!
!!
!
Harmful substances, gases and/or by-products
Please list all substances, gases, and by-products which the product may have come into contact with:
Trade/product name
Manufacturer
Chemical name
(preferably with formula)
Precautions associated
with substance
Action in case of human
contact
Description of product
Type
Part number
Serial number
Reason for return
!
!
!
!
Operating fluid(s) used
(Must be drained before shipping.)
The product is free of any sub-
stances which are damaging to
health yes
!
This form can be downloaded
from our website.
2) Products thus contami-
nated will not be ac-
cepted without written
evidence of decontami-
nation!
