124 FSM4000 D184B140U02
13.4 Return form
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?
Yes No
If yes, which type of contamination (please place an X next to the applicable items)?
Biological Corrosive / irritating Combustible (highly / extremely combustible)
Toxic Explosive Other toxic substances
Radioactive
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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