Appendix
84 265Dx, 265VS IM/265D/V-EN-02
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Statement on the contamination of devices and components
Repair and/or maintenance work will only be performed on devices and components if a statement form has been
completed and submitted.
Otherwise, the device/component returned may be rejected. This statement form may only be completed and
signed by authorized specialist personnel employed by the operator.
Customer details:
Company:
Address:
Contact person: Telephone:
Fax: E-mail:
Device details:
Type: Serial no.:
Reason for the return/description of the defect:
Was this device used in conjunction with substances which pose a threat or risk to health?
F Yes F No
If yes, which type of contamination (please place an X next to the applicable items)?
Biological F Corrosive/irritating F Combustible (highly/extremely
combustible) F
Toxic F Explosive F Other toxic substances F
Radioactive F
Which substances have come into contact with the device?
1.
2.
3.
We hereby state that the devices/components shipped have been cleaned and are free from any dangerous or
poisonous substances.
Town/city, date Signature and company stamp
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