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FEM630 | ELECTROMAGNETIC FLOWMETER | OI/FEM630-EN REV. A
15 Appendix
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: Email:
Device details:
Type: Serial no.:
Reason for the return/description of the defect:
Which substances have come into contact with the device?
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
Yes
biological
toxic
radioactive
corrosive / irritating
explosive
Was this device used in conjunction with substances which pose a threat or risk to health?
No
combustible (highly /
extremely combustible)
other toxic substances
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