Health And Safety Clearance Form - vacuubrand DVR 2 Mode D'emploi

Health and safety clearance form

Declaration concerning safety, potential hazards and safe disposal of waste, e. g. used oil.
Safety and health of our staff, laws and regulations regarding the handling of dangerous goods, occupational health and safety
regulations, safety at work laws and regulations regarding safe disposal of waste, e. g. waste oil, require that for all pumps and
other products this form must be send to our office duly completed and signed before any equipment is dispatched to our
premises. Products will not be accepted for any procedure and handling and repair / DKD calibration will not start
before we have received this declaration.
a) Fax or post a completed copy of this form to us in advance. The declaration must arrive before the equipment. Enclose
a second, completed copy with the product. If the product is contaminated you must notify the carrier (GGVE, GGVS,
RID, ADR).
b) Inevitably, the repair process will be delayed considerably, if this information is missing or this procedure is not obeyed. We
hope for your understanding for these measures which are beyond our control and that you will assist us in expediting the
repair procedure.
c) Make sure that you know all about the substances which have been in contact with the equipment and that all
questions have been answered correctly and in detail.
1. Product (Model): ........................................
2. Serial No.: ..................................................
3. List of substances in contact with the
equipment or reaction products:
3.1 Chemical/substance name, chemical
symbol:
a) ...................................................................
b) ...................................................................
c) ...................................................................
d) ...................................................................
3.2 Important informations and precautions,
e. g. danger classification:
a) ...................................................................
b) ...................................................................
c) ...................................................................
d) ...................................................................
4. Declaration (please mark as applicable):
❑
4.1 for non dangerous goods:
We assure for the returned product that
- neither toxic, corrosive, biologically active, explosive, radio-
active nor contamination dangerous in any way has
occurred.
- the product is free of dangerous substances.
- the oil or residues of pumped media have been drained.
❑
4.2 for dangerous goods:
We assure for the returned product that
- all substances, toxic, corrosive, biologically active, explo-
sive, radioactive or dangerous in any way which have
pumped or been in contact with the product are listed in 3.1,
that the information is complete and that we have not
withheld any information.
- the product, in accordance with regulations, has been
❑ cleaned ❑ decontaminated
VACUUBRAND GMBH + CO KG
-Vakuumtechnik im System-
© 2001 VACUUBRAND GMBH + CO KG Printed in Germany
❑ sterilized.
D-97866 Wertheim - Postfach 1664
D-97877 Wertheim - Alfred-Zippe-Str. 4
Tel. (++49)9342 / 808-0 - Fax (++49)9342 / 59880
5. Way of transport / carrier:
...........................................................................................
Day of dispatch to VACUUBRAND:
...........................................................................................
If the paint is damaged, we wish a repaint or
a replacement of parts due to optical
aspects at our expense (see "Notes on return
to the factory"):
❑ yes
We declare that the following measures -
where applicable - have been taken:
- The oil has been drained from the product.
Important: Dispose of according to national
regulations.
- The interior of the product has been cleaned.
- All inlet and outlet ports of the product have been
sealed.
- The product has been properly packed, if necessary,
please order an original packaging (costs will be
charged) and marked as appropriate.
- The carrier has been informed about the hazardous
nature of the goods (if applicable).
We assure VACUUBRAND that we accept liability for any
damage caused by providing incomplete or incorrect
information and that we shall indemnify VACUUBRAND
from any claims as regards damages from third parties.
We are aware that as expressed in § 823 BGB (Public
Law Code of Germany) we are directly liable for injuries or
damages suffered by third parties, particularly
VACUUBRAND employees occupied with handling/
repairing the product.
Signature: ...........................................................................
Name (print): ......................................................................
Job title (print): ...................................................................
Company´s seal: ...............................................................
Date: ...................................................................................
❑ no