Declaration of Contamination of Compressors, Vacuum Pumps and Components
The repair and / or servicing of compressors, vacuum pumps and components will be carried out only if a correctly completed declaration has been sub-
mitted. Non-completion will result in delay. The manufacturer can refuse to accept any equipment without a declaration.
A separate declaration has to be copleted for every single component.
This declaration may be completed and signed only by authorised and qualified staff.
Customer/Dep./Institute: ________________________________
___________________________________________________
Address ___________________________________________
___________________________________________
Person to contact: ___________________________________
Phone: __________________ Fax: __________________
Order number of customer: ______________________________
Reason for returning
"
applicable please mark
# repair # chargeable # warranty
# Austausch # chargeable # warranty
# DKD-calibration # Factory calibration
restoring goods because of following reason:
# rent/loan # for credit # against exchange
# exchange already received/arranged
A. Description of the equipment (machine or component) Ancillary equipment
Type: _______________________________________ __________________________________________________
Part number: _______________________________________ __________________________________________________
Serial number: _______________________________________ __________________________________________________
Type of oil used: _______________________________________ __________________________________________________
B. Condition of the equipment
No Yes No Contamination: No Yes
1. Has the equipment been used ## toxic ##
2. Drained (Product/service fluid) ## corrosive ##
3. All openings sealed airtight # mmicrobiological ##
4. Purged ## explosive ##
If yes which cleaning agent: _______________________________________ radioactive ##
and which method of cleaning: _______________________________________ other harmful substances ##
C. Description of processed substances (Please fill in absolutely)
1. What substances have come into contact with the equipment:
Trade name and / or chemical term of service fluids and substances processed, properties of the substances; According to safety data sheet
(e.g. toxic, inflammable, corrosive, radioactive)
Tradename: Chemical name: Residues:
a) ____________________________________________________________________________________ # Yes # No
b) ____________________________________________________________________________________ # Yes # No
c) ____________________________________________________________________________________ # Yes # No
d) ____________________________________________________________________________________ # Yes # No
Yes No
2. Are these substances harmful? ##
3. Dangerous decomposition products when thermally loaded ##
Which:
Components contaminated by microbiological, explosive or radioactive products will not be accepted
without written evidence of decontamination.
D. Legally binding declaration
I / we hereby declare that the information supplied on this form is accurate and sufficient to judge any contamination level.
Name of authorised person (block letters): ____________________________
date _____________ signatur of authorised person ___________________________
firm stamp
© Leybold Vacuum Köln
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