page 54 of 57
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) in contact with the device / which have been pumped:
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
6. Prior to return to the factory the device has been decontaminated.
☐
yes
☐
no
Description of the decontamination method and the test / verification procedure:
..............................................................................................................................................................
..............................................................................................................................................................
7. The device is free of hazardous, harmful substances.
☐
yes
☐
no
8. Protective measures required for VACUUBRAND employees:
..............................................................................................................................................................
9. 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
10. 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 listed in section “Return to the factory”.
By our signature below, we acknowledge that we accept liability for any damage caused by providing in-
complete or incorrect information and that we shall indemnify VACUUBRAND from any claims as regards
damages from third parties. We are aware that as expressed in § 823 BGB (Public Law Code of Ger
-
many) we are directly liable for injuries or damages suffered by third parties, particularly VACUUBRAND
employees occupied with handling/repairing the product.
Shipping of the device must take place according to regulations.
Name: ....................................................................... Signature: ..............................................................
Job title: .................................................................... Company’s seal:
Date: .......................................................................
Release for repair grant by VACUUBRAND (date / signature):
..............................................................
Devices will not be accepted for any handling before we have received this declaration.
Please read and comply with ”Notes on return to the factory”.
Oil filled pumps: Drain oil prior to shipping absolutely!
VACUUBRAND GMBH + CO KG
Alfred-Zippe-Straße 4
97877 Wertheim, Germany
Tel.: +49 9342 808-5660
Fax: +49 9342 808-5666
E-Mail: [email protected]
www.vacuubrand.com
