Bibby Scientific Stuart RE3011C Instructions De Service page 19

Damage Report
Bibby Scientific Limited
Beacon Road, Stone
Staffordshire
ST15 0SA, UK
Company / Facility
Street
Post Code / Town
1. Description of the fault: (Which fault occurred?)
2. Conditions of use:
a) Were the pumps / components in use?
b) Which oil was used? *
c) Field of application (load, process, use):
3. Type of contamination of pumps / components:
1)
a) toxic **
1)
b) corrosive **
1)
c) microbiological **
1)
d) explosive
1)
e) radioactive **
f) other harmful substances
* In the case of rotary vane pumps
and roots pumps (Important!)
Type(s) of substances or process-related reaction products which came into contact with the pumps/ components:
1)
Commercial name /
Product name / Manufacturer
1.
2.
3.
4.
Are the pumps / components free of harmful substances?
4. Legally binding declaration:
I/ We declare that the statements here are correct and complete.
The pumps / components are shipped in accordance with the legal requirements. Hereby we order the repair.
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Contact:
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Department:
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Date:
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Legally binding signature:
The repair can only be made if a completely filled out damage report is received. Otherwise the work may be delayed. Our general terms of delivery
and payment apply.
1)
Answer all questions or mark with
the required measures are charged to you.
RE3011C E
Tel: +44 (0)1785 812121
Fax: +44 (0)1785 810405
Email: info@bibby-scientific.com
www.bibby-scientific.com
1)
** Pumps / components will only be accepted if proof is provided that they have been properly cleaned.
By arrangement, cleaning can be done by Bibby Scientific Limited.
1)
Chemical name
(possibly formula)
yes or no. If a box is not filled out, we automatically suppose that there was a contamination and
Damage Report
Order No.:
Type No.:
Type:
yes
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
yes
yes
yes
yes
yes
yes
1)
Actions to be taken if
1)
Danger class
harmful substances escape
yes
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Phone:
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Fax:
Company Stamp:
Return Authorization No.
RNA:
Date of Purchase:
Serial No.:
no
no
no
no
no
no
no
1)
First aid in case
of accidents
no
(EN)
2015-08-19