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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:
_____________________________________
A. Description of the Leybold product
Material description: ______________________________________
Catalog number: ________________________________________
Serial number: _________________________________________
Type of oil (Forevacuum pumps):
B. Condition of the equipment
1. Has the equipment been used 1)
2. Drained (Product/service fluid)
3. All openings sealed airtight
4. Purged
If yes which cleaning agent:
and which method of cleaning: ________________________________________
1) if answered with "No" go to D.
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:
a) _______________________________________________________________________________________________________
b) _______________________________________________________________________________________________________
c) _______________________________________________________________________________________________________
d) _______________________________________________________________________________________________________
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__________________________
32
GA02300_000_23 - 03/2010
__________________________________
___________________________
________________________________________
Reason for return
Repair
chargeable
Exchange
exchange already arranged / received
Return only:
rent
Calibration:
DKD
Quality test certificate DIN 55350-18-4.2.1
Failure description: __________________________________
__________________________________________________
Additional parts: _____________________________________
Application Tool: _____________________________________
Application Process:
No 1)
Yes
No
Chemical name:
No
Yes
applicable please mark
warranty
chargeable
warranty
loan
for credit
Factory calibration
_________________________________
Contamination:
oxic
corrosive
flammable
explosive 2)
radioactive 2)
microbiological 2)
other harmful substances
firm stamp
No 1)
Yes
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