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Declaration of Contamination of Compressors, Vacuum Pumps and Components
The repair and / or servicing of compressors, va cuum pumps and components will be carried out only if a correctly completed declaration has
been submitted. Non-completion will result in delay. The manufacturer can refuse to accept any equipment without a declaration.
A separate declaration has to be completed for each single component.
This declaration may be completed and signed only by authorized and qualified staff.
:
Customer/Dep./Institute
Address :
Person to contact:
Phone :
End user:
A. Description of the Leybold product:
Material description :
Catalog number:
Serial number:
Type of oil (ForeVacuum-Pumps) :
B. Condition of the equipment
1
1
. Has the equipment been used
.
2. Drained (Product/service fluid)
3. All openings sealed airtight
4. Purged
If yes, which cleaning agent
and which method of cleaning
1)
If answered with "No", go to D.
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)
X
Tradename:
a)
b)
c)
d)
2. Are these substances harmful ?
3. Dangerous decomposition products when heated ?
If yes, which ?
2)
Components contaminated by microbiological, explosive or radioactive products/substances 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 authorized person (block letters) :
Date
17200001_002_C0
© Leybold
22
GA02314_000_C0 - 11/2016 - © Leybold
Fax:
Failure description:
Additional parts:
Application-Tool:
Application- Process:
No
1)
Yes
Chemical name:
No
signature of authorized person
Reason for return:
Repair:
chargeable
Exchange:
chargeable
Exchange already arranged / received
Return only:
rent
Calibration:
DKD
Quality test certificate DIN 55350-18-4.2.1
No
Contamination :
toxic
corrosive
flammable
explosive
2)
2)
radioactive
microbiological
other harmful substances
Yes
firm stamp
applicable please mark
warranty
warranty
loan
for credit
Factory-calibr.
No
1)
Yes
2)
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