Grundfos DMX 221 Notice D'installation Et De Fonctionnement page 55

Appendix B
B.1. Safety declaration
• Please copy, fill in and sign this sheet and attach it to the product returned for service.
• Fill in this document using English or German language.
Fault description
• Please make a circle around the damaged part.
• In the case of an electrical or functional fault, please mark the cabinet.
• Please give a short description of the fault and indicate if the diaphragm is damaged:
Declaration
We hereby declare that this product is free from hazardous chemicals, biological and radioactive substances:
Type designation (see nameplate):
Product number:
The product was used with the following dosing medium:
No dosing medium or water:
A chemical solution, name:
Date and signature:
Company stamp:
813