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550_us
Goods return declaration (copy specimen)
Legal regulations for the protection of the environment and personnel require that you include the
completed and signed goods return declaration with your dispatch documents.
If this declaration is not completed or not included with the dispatch documents, your return
will not
be processed!
If the valve / device was operated with poisonous, corrosive, flammable, aggressive or water-
endangering media, all medium wetted parts must be emptied carefully, decontaminated and rinsed.
Select an appropriate transport container, label it with the name of media which the valve / device has
been in contact. This serves to avoid personal injury or damage to property from the media remains.
Please tick the relevant warning labels:
We herewith declare that the returned parts were cleaned and that complying with Danger Protection
Regulations there is no danger from the remains of media for persons or for the environment.
Location, Date . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Stamp / signature . . . . . . . . . . . . . . . . . . . . . . . . . .
radioactive explosive corrosive poisonous harmful
to health
bio-
hazardous
oxidising harmless
Valve / device information:
Type: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Year of manufacture: . . . . . . . . . . . . . . . . . . . . . . . .
Serial number: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Ambient temperature: . . . . . . . . . . . . . . . . . . . . . . . .
Media: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Concentration: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Operating temperature: . . . . . . . . . . . . . . . . . . . . . .
Operating pressure: . . . . . . . . . . . . . . . . . . . . . . . . .
Viscosity: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Solids content: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Company details:
Company: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Address: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Contact person: . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Telephone number: . . . . . . . . . . . . . . . . . . . . . . . . .
Fax number: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
E-Mail: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Reason for return:
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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