Health And Safety Clearance Form - vacuubrand RE 2 Instructions For Repair

Rotary vane pumps, chemistry-hybrid-pumps, vacuum gauge

Table of Contents

Health and safety clearance form

1. Device (Model): ..................................................................................................................................................

2. Serial no.: ...........................................................................................................................................................

3. Reason for return / malfunction: .........................................................................................................................

............................................................................................................................................................................

4. Has the device been used in a copper process step (e.g., semiconductor production):

5. Substances (gases, liquids, solids, biological material, e. g. bacteria, viruses) in contact with the device /

which have been pumped:

............................................................................................................................................................................

6. Risk level of the used biological material:

* Contact the VACUUBRAND service absolutely before dispatching the device.

** Devices which have been in contact with biological substances of risk level 3 or 4 cannot be checked, main-

tained or repaired. Also decontaminated devices must not returned to VACUUBRAND due to a residual risk.

7. Radioactive contamination:

8. Prior to return to the factory the device has been decontaminated:

............................................................................................................................................................................

9. All parts of the device are free of hazardous, harmful substances:

10. Protective measures required for service staff:

............................................................................................................................................................................

11. 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):

12. 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 "Repair - Maintenance - Return - Calibration".

By our signature below, we acknowledge that we accept liability for any damage caused by providing incom-

plete 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 Germany) 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)

Protective measures:

VACUUBRAND GMBH + CO KG

Alfred-Zippe-Straße 4

97877 Wertheim - Germany

Das Dokument darf nur vollständig und unverändert verwendet und weitergegeben werden. Es liegt in der Verantwortung des

Anwenders, die Gültigkeit dieses Dokumentes bezüglich seines Produktes sicher zu stellen.

Documents are only to be used and distributed completely and unchanged. It is strictly the users´ responsibility to check carefully

the validity of this document with respect to his product.

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