Declaration Of No Objection - Heidolph Hei-MIX Titramax 100 Notice D'instructions

Annex

Declaration of no objection

Enclose the declaration of no objection, duly completed, with your device return.
Submissions without a declaration of no objection cannot be processed!
1. Information on the device
Item number:
Serial number:
Reason for submission:
Does this product pose a risk to people and/or the environment due to
its use for processing substances that are hazardous to health, the envi-
2.
ronment and/or biohazardous? Please mark with a cross and complete
the information!
NO YES
3. Information on the client/sender:
Full name:
Company/institution:
Department/working
group:
Address:
Zip code, city:
Country:
Phone:
E-Mail:
4. Legally binding declaration
With his signature, the client/submitter declares the completeness and correct-
ness of his details. Missing or incorrect information obligates to compensation for
damages.
Date
If YES, with which substances did the device come
into contact?
If NO, what cleaning and/or decontamination
measures were carried out?
Signature, company stamp
51