GA01300_0902 - 04/2006 - © by Leybold Vacuum
45
vacuum
Declaration of Contamination of Compressors, Vacuum Pumps and Components
The repair and / or servicing of compressors, vacuum pumps and components will be carried out only if a correctly completed declaration has been sub-
mitted.
Non-completion will result in delay
. The manufacturer can refuse to accept any equipment without a declaration.
A separate declaration has to be completed for each single component.
This declaration may be completed and signed only by authorised and qualified staff.
Customer/Dep./Institute:
________________________________
___________________________________________________
Address
___________________________________________
___________________________________________
Person to contact:
___________________________________
Phone:
__________________ Fax: __________________
End user:
__________________________________________
Reason for return
applicable please mark
Repair
chargeable
warranty
Exchange
chargeable
warranty
exchange already arranged / received
Return only:
rent
loan
for credit
Calibration:
DKD
Factory calibration
Quality test certificate DIN 55350-18-4.2.1
A. Description of the Leybold product
Failure description:
___________________________________
Material description: _____________________________________
___________________________________________________
Catalog number:
_______________________________________
Additional parts:
_____________________________________
Serial number:
_______________________________________
Application Tool:
_____________________________________
Type of oil (Forevacuum pumps): ____________________________
Application Process:
__________________________________
B. Condition of the equipment
No
1)
Yes
No
Contamination:
No
1)
Yes
1. Has the equipment been used
1)
toxic
2. Drained (Product/service fluid)
corrosive
3. All openings sealed airtight
flammable
4. Purged
explosive
2)
If yes which cleaning agent:
_______________________________________
radioactive
2)
and which method of cleaning:
_______________________________________
microbiological
2)
1)
if answered with “No” go to
D
.
other harmful substances
C. Description of processed substances (Please fill in absolutely)
1. What substances have come into contact with the equipment:
Trade name and / or chemical term of service fluids and substances processed, properties of the substances; According to safety data sheet
(e.g. toxic, inflammable, corrosive, radioactive)
Tradename:
Chemical name:
a) ______________________________________________________________________________________________________
b) ______________________________________________________________________________________________________
c) ______________________________________________________________________________________________________
d) ______________________________________________________________________________________________________
No
Yes
2. Are these substances harmful?
3. Dangerous decomposition products when heated?
If yes, which? ___________________________________________________________________________________________
2)
Components contaminated by microbiological, explosive or radioactive products/substances will not be accepted
without written evidence of decontamination.
D. Legally binding declaration
I / we hereby declare that the information supplied on this form is accurate and sufficient to judge any contamination level.
Name of authorised person (block letters):
____________________________
Date _____________ Signatur of authorised person ___________________________
firm stamp
Date of issue: Apr.08.2005 / revision V01 (GA)
© Leybold Vacuum
