Homa FW-TP 4/1 Manuel D'instructions Original page 84

11. Declaration of Contamination
The repair if the instruments can only be accomplished if this document is filled out completely and accurately.
ANSWER by FAX: HOMA Pumpenfabrik GmbH:... +49 (0) 2247 702 - 44
Pump data:
Type:
Part No:
Serial no:
Reason for return:
Contamination of the instruments:
toxic
corrosive
microbiological
explosive
radioactive
other substances
Legally binding declaration:
We hereby certify that the returned parts have been cleaned carefully. To the best of our knowledge, they are free from any residues in dange-
rous quantities.
Company:
Street:
Contact person:
Phone:
e-mail:
Date
84
no □ yes □ substance:
no □ yes □ substance:
no □ yes □ substance:
no □ yes □ substance:
no □ yes □ substance:
no □ yes □ substance:
Zip code, City:
Fax:
Company stamp and signature