Appendix; Return Form - ABB RHDE250 Series Operating Instruction

RHDE250 to RHDE4000 (Contrac) ELECTRICAL ROTARY ACTUATOR | OI/RHDE250_4000-EN REV. B

16 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:
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
Telephone:
Email:
 corrosive / irritating
 explosive
Serial no.:
 combustible (highly / extremely
combustible)
 other toxic substances
Signature and company stamp
41