Declaration Of Contamination - Homa H 501 W(A) Originalbetriebsanleitung

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Declaration of Contamination

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The repair if the instruments can only be accomplished if this document is filled out completely and accurately.
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ANSWER by FAX: HOMA Pumpenfabrik GmbH:... +49 (0) 2247 702 - 44
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Pump data:
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Type:
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:
Part No
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Serial no:
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Reason for return:
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Contamination of the instruments:
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toxic
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corrosive
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microbiological
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explosive
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radioactive
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other substances
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Legally binding declaration
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We hereby certify that the returned parts have been cleaned carefully. To the best of our
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knowledge, they are free from any residues in dangerous quantities.
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Company:
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Street:
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Contact person:
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Phone:
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e-mail:
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Date
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Address: Industriestr. 1, D-53819 Neunkirchen-Seelscheid
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Phone: +49 (0) 2247 702-0,
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Fax: +49 (0) 2247 702-44
Email: info@homa-pumpen.de, www.homa-pumpen.de
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Zip code, City:
Fax:
Company stamp and signature
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Dokument Nr. F-KE-01-090211-303