Appendix
9.3 Declaration of harmlessness
This declaration of harmlessness of th e operator is used to ensure work safety
and the protection of our employe es, the transpor t company and the environment
from harmful effects when handling dangerous materials as well as to protect you
from claims for compensation.
Every commercial company is obligated to comply with the legal regulations on work
safety, set forth for example in Germany in the Workplace Ordinance (ArbStättV),
the Accident Prevention Regulations (UVV), the Hazardous Substances Ordin ance
(GefStoffV) and the applicable environmental regulations.
Please copy this
document and
send it together
with the pump.
www.allweiler.de/
en/sales-service/
downloads
When returning pumps and their accessories, please send them back to us in a properly cleaned condition (safe and harmless
for health and en vironment) a nd confirm the safety and harmlessne s s of the medium used.
If used with toxic, microbiological, exp losi v e, rad ioa ctive or other hazardous substances, the safety data sheet must be
provided to us and enclosed to the sh ipment.
Failure to follow the above instructions will lead to the implementation of measures that ensure the safe handling of the
pump or the device, at your cost. We reserve the right to reject contaminated pumps and accessories and to return them
forcleaningatyourcost!
This declaration of harmlessness must be attached clearly visible outside of the packaging of the return shipment, and if
possible s ent in advance by e-mail including the safety data sheet, if applicable, to:
service-emea-gr@circor.com. Please understand that return shipments without a declaration of harmlessness cannot be
processed until such declaration is received.
Pump type
Serial number:
Was the pump operated with hazardous s ub stances or other
media that are hazardous t o health or the enviro nment?
❏ No
❏ Yes
Medium used:
______________________________________________
UN / CAS number (see safety data sh eet):
______________________________________________
❏ The pump has been thoroughly drained and cleaned outside
and i nside prior to dispatch or pro v ision.
❏ Special safety precautions are not necessary.
❏ Special sa fety precautions regarding residual liquid, rinsing
media, personal protective equipment and di sposal are
necessary (safety data sheets a re required and must be sent
in advance/e nclosed).
❏ Aside from the medium specified, are there any other safety
aspects that need to be observed (for example, the cleaning
medium used)?
If yes, which:
_______________________________________________
❏ U p-to-date safety data sheet enclosed.
We do not accept return shipment of pumps or parts thereof that have been exposed to radioactive or microbiological
contaminatio n and that were not properly decont aminated.
Contact:
Tel./fax/e-mail:
Legally binding declaration:
We hereby certify that we have completed this declaration fully and truthfully to the bes t of our kn owledge. The dispatch
is performed in compliance with all legal requirements that apply to the packaging, shipping, and labeling of hazardous
substances. The sender is liable for all damages caused by unmarked decontaminations of the returned object.
Place
,date
Signature Stamp
Tab. 53 Declaration of harmlessness
56 AE BA-2020.05 en-US 260371 – 176-982/0
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