TEIP11, TEIP11-PS | 42/18-46-EN Rev. L 15
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12 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: E-Mail:
Device details:
Typ: 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 Explosiv 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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