LEYBOLD SOGEVAC SV 40 Mode D'emploi page 27

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 declaration.
This declaration can only be completed and signed by authorised and qualified staff.
1.Description of Vacuum Equipment and
Components
- Equipment type/model :
- Code No :
- Serial No :
- Invoice No :
- Delivery Date :
3.Condition of the Vacuum Equipment and
Components
- 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)
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 equipment :
Trade name
Product name
Manufacturer
1.
2.
3.
4.
5.
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,
Transportation and Labelling of Dangerous Substances.
Name of organisation or compagny :
Address :
Tel :
Fax :
Name :
Job Title :
Date :
Legally binding signature :
Copyright by MaschinenbauVerlag GmbH, Lyoner Straße 18, 6000 Frankfurt/M. 71 Order No. : 2122
c
Chemical
name
(or symbol)
Telex :
Compagny stamp :
2.Reason for Return
4.Process related Contamination of Vacuum
Equipment and Components
- toxic
- corrosive
- explosive
- biological hazard
- radioactive
- other harmful substances
Dangerous Measures
material if spillage
class
Post code :
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
First aid in
case of
human contact
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