Declaration about the Contamination of
Richter Pumps, -Valves
and Components
Prepared:
CRQ/Lam
on
:
Nov. 13, 2006
Page:
2
QM-Nr.:
0912-16-2001_de/4-
07
Approved:
CRQ/Zu
on
:
Nov. 13, 2006
of :
2
The repair and/or maintenance of pumps, valves and components can only be implemented if a completely filled out declaration is
available. If this is not the case, delay of the work will occur. If this declaration is not attached to the devices, which have to be
repaired, the transmission can be rejected.
Every aggregate has to have i
t’s own declaration.
This declaration may be filled out and signed only by authorized technical personnel of the operator.
Contractor/dep./institute :
Reason for transmitting
x
Please mark the applicable
Repair:
□
subject to fee
□
Warranty
Street :
Austausch:
□
subject to fee
□
Warranty
Postcode, city :
□
Exchange/ Replacement already initiated/received
Contact person :
Return
:
□
Leasing
□
Loan
□
for credit note
Phone :
Fax :
End user
:
A. Details of Richter-product:
Failure description:
Classification:
Article number:
Serial number:
B. Condition of the Richter-product:
no
1)
yes
no
Contamination :
no
1)
yes
Was it in operation ?
□
□
toxic
□
□
Drained (product/operating supply item) ?
□
□
caustic
□
□
All openings hermetically locked!
□
inflammable
□
□
Cleaned ?
□
□
explosive
2)
□
□
If yes, with which cleaning agent:
mikrobiological
2)
□
□
and with which cleaning method:
radioactive
3
)
1)
if "no", then forward to
D
.
other pollutant
□
□
2)
Aggregates, which are contaminated with microbiological or explosive substances, are only accepted with
documented evidence of an approved cleaning.
3)
Aggregates, which are contaminated with radioactive substances, are not accepted in principle.
C. Details of the discharged materials (must be filled out imperatively)
1.
With which materials did the aggregate come into contact ?
Trade name and/or chemical designation
of operational funds and discharged materials, material properties, e.g. as per safety data sheet (e.g. toxic,
inflammable, caustic)
X Trade name:
Chemical designation:
a)
b)
c)
d)
no
yes
2. Are the materials specified above harmful to health ?
□
□
3. Dangerous decomposition products during thermal load ?
□
□
If yes, which ones?
D. Mandatory declaration:
We assure that the data in this explanation are truthful and complete and as a signatory I am
able to form an opinion about this. We are aware that we are responsible towards the contractor for damages, which results
from incomplete and incorrect data. We commit ourselves to exempt the contractor from claims for damages of thirds
resulting from incomplete or incorrect data. We are aware that we are directly responsible towards thirds, irrespective of this
declaration, which belongs in particularly to the employees of the contractor consigned with the handling repair of the product.
Company stamp
Name of the authorized person
(in block letters):
Date
Signature
