Usage Status Check Sheet (for use in Instruction Manual)
* For the purpose of safety control of repair personnel, fill in within the heavy line frame and attach
the sheet to the item of which repair is requested.
* In case this sheet were not attached or filled in, your request of repair and service may not be
accepted.
* In accordance with the Private Information Protection Law, the provided information will be used
only for determining the cause of failure and whether detoxifying washing should be conducted. It
will never be provided to any third person.
Model Name: _______________ Manufacturer’s Serial No.:________________
1. Inhaled Gas * Please be sure to fill in.
(1) Whether there is harmful effect on human bodies
Yes No
(Sing your name below.)
(2) Whether there is unusual smell
Yes No
(3) Type and Name of Gas: ______________________________
* Industrial Safety and Health Law designates particular substances as the materials to be
notified.
2. Usage Status
Operation Method: Approx. ( ) hours per day, ( ) years and ( ) months
□Continuous Operation □Intermittent Operation
Usage: __________________________________
3. Failure Status □Unusual Noise □Abnormal Pressure □Abnormal Actuation □Oil Leakage
Other Symptoms: _______________________________
4. Detail of Request
□Repair (Overhaul) □Regular Checks
5. Others: _____________________________
Company Name: Personnel in charge:
Address:
Tel: Fax: E-mail:
Agent Name; Personnel in charge:
Address:
Tel: Fax:
* In case you do not have any direct transaction with us, please be sure to fill in the agent name.
6. Confirmation
The gas and substance used in this pump or unit is harmless to human bodies, or it is not
contaminated by any substance harmful to human bodies.
Signed
(seal) Date:
*
Please send the parcel to our Service Division. (See attached contact information.)
* In order to avoid a trouble during transportation, please evacuate oil from any oil pump before
shipping.
