Health And Safety Clearance Form - vacuubrand ME 4C NT VARIO Instructions For Use Manual

Health and safety clearance form

Devices will not be accepted for any handling before we have received this declaration.
Please read and comply with "Notes on return to the factory".
Oil filled pumps: Drain oil prior to shipping absolutely!
1. Device (Model): ................................................................... 2. Serial no.: .........................................
3. Reason for return / malfunction:
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4. Has the device been used in a copper process step (e.g., semiconductor production).
5. Substances (gases, liquids, solids) in contact with the device / which have been pumped:
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6. Prior to return to the factory the device has been decontaminated.
Description of the decontamination method and the test / verification procedure:
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7. The device is free of hazardous, harmful substances.
8. Protective measures required for VACUUBRAND employees:
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9. If the paint is damaged, we wish a repaint or a replacement of parts for reason of appearance (repaint
and replacement at customer's expense).
10. Legally binding declaration
We assure for the returned device that all substances, which have been in contact with the device are
listed in section 5 and that the information is complete and that we have not withheld any information. We
declare that all measures - where applicable - have been taken listed in section "Return to the factory".
By our signature below, we acknowledge that we accept liability for any damage caused by providing in-
complete or incorrect information and that we shall indemnify VACUUBRAND from any claims as regards
damages from third parties. We are aware that as expressed in § 823 BGB (Public Law Code of Ger-
many) we are directly liable for injuries or damages suffered by third parties, particularly VACUUBRAND
employees occupied with handling/repairing the product.
Shipping of the device must take place according to regulations.
Name: ....................................................................... Signature: ..............................................................
Job title: .................................................................... Company's seal:
Date: .......................................................................
Release for repair grant by VACUUBRAND (date / signature):
VACUUBRAND GMBH + CO KG
Alfred-Zippe-Straße 4
97877 Wertheim, Germany
page 126 of 129
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Tel.: +49 9342 808-5660
Fax: +49 9342 808-5666
E-Mail: service@vacuubrand.com
www.vacuubrand.com
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