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
submitted.
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
8
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
No1) Yes No
Contamination:
No1) Yes
1. Has the equipment been used1)
oxic
2. Drained (Product/service fluid)
corrosive
3. All openings sealed airtight
flammable
4. Purged
explosive2)
If yes which cleaning agent:
________________________________________
radioactive2)
and which method of cleaning: ________________________________________
microbiological2)
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
32
GA02300_000_23 - 03/2010
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