Please copy and send in with your apparatus!
15. Declaration of harmlessness
Declaration of harmlessness
(please fill out a separate form for each appliance – e.g. pump or accessory)
We forward the following dosing equipment for repairs:
Type (dosing pump or accessory): ____________________________________________________
Part-no.: _______________________________________________________________________
Order-no.: ______________________________________________________________________
Delivery date: ___________________________________________________________________
Reason for repair: ________________________________________________________________
______________________________________________________________________
Medium used: ____________________________________ Properties:
irritant:
yes/no
corrosive: yes/no
We hereby certify that the machine has been thoroughly cleaned inside and out before its dispatch and that
it is free from health risk chemical, biological and radioactive materials as well as having been drained of
oil. *)
If Lutz-Jesco find it necessary to carry out further cleaning work, we accept the charge will be made to us.
We certify that the aforementioned information is correct and complete and that the unit is dispatched in
compliance with legal requirements.
Company / address:
Phone:
Fax:
Fax:
E-Mail:
Customer-number:
Contact person:
________________________
____________________________
Date
Signature / stamp
*) If not applicable please cross out!
Please send with the unit and display
Lutz-Jesco GmbH, Am Bostelberge 19
anon the outer packaging.
0900 Wedemark, Germany
