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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 I 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
substancesin
contact
with
the
equipment
or
reaction products:
3.1
Chemical/substancename,
chemical symbol:
a)
...................................................................
b)
...................................................................
c)
...................................................................
d)
...................................................................
3.2 Importantinformationsand precautions,
e.
g. dangerclassification:
a)
...................................................................
b)
...................................................................
c)
...................................................................
d)
...................................................................
4.
Declaration(please markas applicable):
0
4.1
for
non dangerousgoods:
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.
0
4.2
for
dangerousgoods:
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
0 cleaned 0 decontaminated 0 sterilized.
5.
Way
of
transport
I carrier:
Day of dispatch to VACUUBRAND:
If
the
paint
is
damaged, we
wish
a repaint
or
a replacement
of
partsdue
to
optical
aspectsat
our
expense(see "Notes
on
return
to the factory"):
Dyes
Dno
We declarethatthe
following measures-
where
applicable-
havebeen 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 andthat
we
shall indemnifyVACUUBRANDfrom
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:
...................................................................................
VACUUBRAND GMBH+CO
KG
-TechnologyforVacuum Systems- Alfred-Zippe-Str. 4 - 97877 Wertheim
© 2001 VACUUBRANO
GMBH+
CO KG Printed in Germany
Tel.:
+49 9342 808-0 -
Fax:
+49 9342 808-450
Web:
www.vacuubrand.de