Declaration of Contamination
concerning compressors, blowers, vacuum pumps and components
Gera/QUM/V-190501 Kontaminierungserklärung Gebläse-2/28.09.2007-E
Repair and/or maintenance work will only be carried out on items for which a Declaration of Contamination form has been filled out
and attached.
A completed Declaration is required for each item.
Any item not accompanied by a Declaration is liable to be
returned untouched. Items that have been contaminated with microbiological, explosive or radioactive substances will only be
accepted when accompanied by confirmation that they have been
fully decontaminated
according to regulation.
This Declaration may only be filled out and signed by the authorized representative of the ordering party (sender of the item).
Specification of the item:
Model/type name: _________________________________
Accessories:
Part no..:
_________________________________
_________________________________________
Serial no..:
_________________________________
_________________________________________
Oil used:
_________________________________
_________________________________________
Condition of the item:
yes
no
not known
- has it been used?
'
'
'
- emptied/vented?
'
'
'
- all openings airtight closed?
'
'
'
- cleaned / decontaminated?
'
'
'
Cleaning substance used:
____________________________________________________________
Cleaning method:
____________________________________________________________
Information on contaminants:
- with what substances has the item been in contact?
Trade name
Chemical name
Characteristics
a)
b)
c)
d)
yes
no
not known
- Are the substances listed above hazardous to health?
'
'
'
- Are any hazardous substances given off by heating?
'
'
'
Which? _________________________________________________________________________________________
We declare that the information given in this declaration is true and complete and that the signatory is authorized and in a position to
make this declaration. We are aware of our liability for any damages resulting from false or incomplete information given in this
declaration and we engage to hold the contractor free of claims from third parties for compensation for damages resulting from such
incomplete or false information.
Name of the authorized signatory (please print):
_________________________________
_______________ _______________________________
Date
Authorized signature
Sender’s company seal:
Sender/dept.:
______________________________
Contact name:
______________________________
Address:
______________________________
______________________________
Phone / Fax:
______________________________
Reason for sending the item:
(use rear side of form if necessary)
13 Annex
13.3 Declaration concerning contamination
Number: 9_9533 23 E
Assembly and operating manual Blower block
OMEGA 4 B
51
