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Health and safety clearance form
Health and safety clearance form
1. Device (Model): ..................................................................................................................................................
2. Serial no.: ...........................................................................................................................................................
3. Reason for return / malfunction: .........................................................................................................................
............................................................................................................................................................................
4. Has the device been used in a copper process step (e.g., semiconductor production):
☐
yes
☐
no
5. Substances (gases, liquids, solids, biological material, e. g. bacteria, viruses) in contact with the device /
which have been pumped:
............................................................................................................................................................................
............................................................................................................................................................................
............................................................................................................................................................................
............................................................................................................................................................................
6. Risk level of the used biological material:
☐
none
☐
1
☐
2*
☐
3**
☐
4**
* Contact the STARLAB service BEFORE dispatching the device.
** Devices which have been in contact with biological substances of risk level 3 or 4 cannot be checked, main-
tained or repaired and even decontaminated devices must not be returned to STARLAB due to a residual risk.
7. Radioactive contamination:
☐
yes
☐
no
8. I confirm that the device has been decontaminated:
☐
yes
☐
no
Description of the decontamination method and the test / verification procedure:
............................................................................................................................................................................
............................................................................................................................................................................
9. All parts of the device are free of hazardous, harmful substances:
☐
yes
☐
no
10. Protective measures required for service staff:
............................................................................................................................................................................
11. If the paint is damaged, we wish a repaint or a replacement of parts for reason of appearance
(repaint and replacement at customer’s expense):
☐
yes
☐
no
12. Legally binding declaration
We assure for the returned device that all substances, which have been in contact with the device are listed in
section 5 and that the information is complete and that we have not withheld any information. We declare that
all measures (where applicable) have been taken as listed in section “Repair - Maintenance - Return”. By our
signature below, we acknowledge that we accept liability for any damage caused by providing incomplete or
incorrect information and that we shall indemnify STARLAB from any claims as regards damages from third
parties. We are aware that as expressed in § 823 BGB (Public Law Code of Germany) we are directly liable for
injuries or damages suffered by third parties, particularly STARLAB employees occupied with handling/repairing
the product. Shipping of the device has/will be undertaken according to regulations.
Name: .................................................................. Signature: ...........................................................................
Job title: ................................................................... Company’s seal:
Date: ........................................................................
Release for repair grant by STARLAB (date / signature)
:............................................................................................................................
Protective measures:
☐ Protective gloves, safety goggles ☐ Hood ☐ External cleaning
STARLAB International GmbH
Neuer Höltigbaum 38
22143 Hamburg - Germany
T: +49 (0)40 675 99 39 0 F: +49 (0)40 675 99 39 20
E-Mail: [email protected]
www.starlabgroup.com
Summary of Contents for N2400-9001
Page 1: ...page 1 of 36 Hand controller N2400 9001 Instructions for use...
Page 2: ...page 2 of 36...
Page 21: ...page 21 of 36...
Page 35: ...page 35 of 36...
