Appendix; Return Form - ABB TEIP11 Operating Instruction

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12 Appendix

Return form

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:
Typ:
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
Telephone:
E-Mail:
Corrosive / irritating 

Explosiv
Serial no.:
Combustible (highly / extremely combustible)
Other toxic substances
Signature and company stamp
TEIP11, TEIP11-PS | 42/18-46-EN Rev. L 15
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