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Service and Repair Form
Declaration of Contamination of Equipment and Components
Serving and repairs will only be carried out if the conditions for Servicing and Repair are complied with in full, according to
the VACGEN Ltd. Conditions of Sale. A summary of these requirements are included on the inside front cover of the
Operating Instructions. The manufacturer will refuse to accept any equipment without a signed declaration attached to the
OUTSIDE of the packaging. This declaration can only be completed and signed by authorized and qualified staff.
1 Description of Equipment and Components
Equipment Type…………………………………Model Number………………………………………………
Serial Number…………………………………… Your Reference Number……………………………
2
Reasons
for
return
………………………………………………………………………………………………………………………………………
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3 Condition of Equipment
YES ( ) NO ( ) Toxic? YES ( ) NO ( ) Corrosive?
YES ( ) NO ( ) Explosive? YES ( ) NO ( ) Biological Hazard?
YES ( ) NO ( ) Radioactive? YES ( ) NO ( ) Other Harmful Substances?
Equipment and Components that have been contaminated, WILL NOT be accepted without written evidence of
decontamination.
5 Contamination Materials
List all the substances, gases and by-products that may have come in contact with the equipment, giving trade name,
manufacture, chemicals names or symbols.
Please note that any of these listed, must be completely removed, so it is safe to handle and weld, without giving off health
threatening gases. Please enter details below and/or attach data sheets
……………………………………………………………………………………………………………
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6 Legally Binding Declaration
I hereby declare that the information supplied on this form is complete and accurate.
There by stating that the goods offer no risk to health or safety
Organisation………………………………… Name………………………………………………
Country………………………………………… Job Title……………………………………………
Post/ZIP code……………………………… Telephone………………………………………
Email………………………………………………
Signature……………………………………
Date………………………………………………
Return goods to: Address at top
Phone: (0) 1424 851291 Fax (0) 1424 851489 (Form VGF33)
