Essential Information - MIL'S EVISA E65.R Betriebs- Und Wartungshandbuch

A vacuum pump and its accessories may in some cases draw up or be in contact with hazardous substances. For reasons of
safety of the staff or our after sales and repair departments, and in accordance with the regulations, it is mandatory that you
complete this form with the following essential information when returning the equipment to the factory for repair.
Otherwise, the products received will be isolated in a quarantine area and no human intervention may be undertaken.
Machine type:
Serial number:
Date of sending:
Reason for return:
What type of oil is used for the pump: ..............................................................................................................................
Presence of bacteriological filtration:
Presence of bacteriological cartridge:
Does the device contain toxic substances:
Does the device contain corrosive substances:
Does the device contain CMR* substances:
Does the device contain explosive substances:
Does the device contain radioactive substances:
Others: ........................................................................
(*) CMR : carcinogenic - mutagenic - reprotoxic
S If radioactive or explosive materials are present, list the substances of the gas and the by-products:
Product name
Legal declaration
We declare on our honour that the data in this declaration was provided exhaustively, sincerely and factually and that the
undersigned is qualified to judge this. We are aware that we are liable in relation to the contractor for incomplete or
incorrect data. We commit ourselves to exempt the contractor from any responsibility in relation to third parties in
respect of damage and interests owed to incomplete or incorrect data. We are aware that beyond this declaration, our
responsibility is directly engaged in relation to third parties, which includes in particular the employees of the contractor
responsible for handling/repairing the product.
Company : .............................................................................
Street : ...................................................................................
Name (in capital letters): .......................................................
Phone: ...................................................................................
Date: ......................................................................................
32
SAFETY SHEET
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ESSENTIAL INFORMATION

Chemical composition
 YES  NO
 YES  NO
 YES  NO
 YES  NO
 YES  NO
 YES  NO
 YES  NO
 YES  NO
Risk category
Postal code / city: ...............................................................
Fax: .....................................................................................
Position: ..............................................................................
Company seal: ....................................................................
Signature:
First aid
517976-04