ABB CoriolisMaster FCM2000 Operating Instructions Manual page 125

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Statement on the contamination of devices and components
Repair and/or maintenance work will only be performed on devices and components if a statement form has been
completed and submitted.
Otherwise, the device/component returned may be rejected. This statement form may only be completed and
signed by authorized specialist personnel employed by the operator.
Customer details:
Company:
Address:
Contact person:
Fax:
Device details:
Type:
Reason for the return/description of the defect:
Was this device used in conjunction with substances which pose a threat or risk to health?
Yes No
If yes, which type of contamination (please place an X next to the applicable items)?
Biological
Toxic
Radioactive
Which substances have come into contact with the device?
1.
2.
3.
We hereby state that the devices/components shipped have been cleaned and are free from any dangerous or
poisonous substances.
Town/city, date
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D184B111U02
Corrosive/irritating
Explosive
CoriolisMaster FCM2000
Telephone:
E-mail:
Serial no.:
Combustible (highly/extremely combustible)
Other toxic substances
Signature and company stamp
Appendix
125