64
GA 05.139/1.02 - 06/99
S A M P L E
Declaration of Contamination of Vacuum Equipment and Components
The repair and/or service of vacuum equipment and components will only be carried out if a correctly completed declaration has
been submitted. Non-completion will result in delay. The manufacturer could refuse to accept any equipment without a declara-
tion.
This declaration can only be completed and signed by authorized and qualified staff.
1. Description of Vacuum Equipment and Com-
ponents
- Equipment type/model: _________________________________
- Code No.: _________________________________
- Serial No.: _________________________________
- Invoice No.: _________________________________
- Delivery date:
__________________________
2. Reason for Return
____________________________________________
____________________________________________
____________________________________________
____________________________________________
____________________________________________
____________________________________________
3. Condition of the Vacuum Equipment and Com-
ponents
- Has the equipment been used?
yes ❒ no ❒
- What type of pump oil/liquid was used? _________
- Is the equipment free from potentially
harmful substances?
yes ❒ (go to Section 5)
no ❒ (go to Section 4)
4. Process related Contamination of Vacuum
Equipment and Components:
- toxic yes ❒ no ❒
- corrosive yes ❒ no ❒
- explosive*) yes ❒ no ❒
- biological hazard*) yes ❒ no ❒
- radioactive*) yes ❒ no ❒
- other harmful substances yes ❒ no ❒
*) Vacuum equipment and components which have been contaminated by biological explosive or radioactive substances,
will not accepted without written evidence of decontamination!
Please list all substances, gases and by-products which may have come into contact with the equipment:
Trade name
Product name Chemical name Dangerous Measures First aid in case of
Manufacturer (or Symbol) material class if spillage human contact
1.
2.
3.
4.
5.
Copies: Page 1 (white) to manufacturer or representative - Page 2 (yellow) attach to consignment packaging securety - Page 3 (blue) copy for file of sender
5. Legally Binding Declaration
I hereby declare that the information supplied on this form is complete and accurate. The despatch of the contaminated
vacuum equipment and components will be in accordance with the appropriate regulations covering Packaging, Transpor-
tation and Labelling of Dangerous Substances.
Name of organisation or company:_____________________________________________________________________
Address: _____________________________ Post code:______________________________________
Tel.: ______________________________________________________________________________
Fax: _____________________________ Telex: _________________________________________
Name: ______________________________________________________________________________
Job title: ______________________________________________________________________________
Date: _____________________________ Company stamp:
Legally binding signature:____________________________________________________________________________
Copyright © 1991 by MaschinenbauVerlag GmbH, Lyoner Straße 18, 6000 Frankfurt/M. 71 Order No.: 2121
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