39 255548 Rev.1
10.17 Certifi cate of conformity
Please copy this form and return it to the manufacturer together with the pump/aggregate.
Th
e pump/pump aggregate including accessories for which we, the undersigned, have placed an inspection/repair order
or which has been returned by us together with this certifi cate of conformity,
Designation:
_____________________________________________________________________________
Type:
_____________________________________________________________________________
Serial number:
_____________________________________________________________________________
☐
has not been in contact with hazardous substances.
☐
has been used in the area of application of:
☐
and has been in contact with the following harmful substances or substances subject to mandatory
labelling:
Trade name
Chemical designation
Properties
(e.g. toxic, infl ammable, caustic)
☐
Th
e pump/pump aggregate has been completely drained, fl ushed and cleaned both inside and outside in
accordance with the operating instructions.
☐
Further handling of the pump/aggregate does not require special safety precautions.
☐
Th
e following safety precautions must be observed when handling the pump/aggregate:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
☐ Safety data sheets in accordance with national regulations are enclosed.
Legally binding statement
We herewith certify that all data given above are correct and complete and that I, the undersigned, am in a position to
confi rm this.
We acknowledge our liability towards the contractor for any damage arising from incomplete or incorrect data.
We agree to hold harmless the contractor against damage claims of third parties due to incomplete or incorrect
data.
We know that, independent of this statement, we have to take direct liability towards third parties, which
particularly refers to the staff of the contractor responsible for handling, repair and maintenance.
City, date
: ________________________________
Name:
__________________________________
Company
________________________________
Signature
: __________________________________
stamp:
Certifi cate of conformity
Tab. 57 Certifi cate of conformity
