Form For Statement On Safety - ProMinent DULCOMETER PH-501 Assembly And Operating Instructions Manual

Form for statement on safety

Statement on health safety and on the protection of the environment
For the safety of our employees and to comply with statutory requirements on handling substances harmful to the health and
the environment, this statement must be enclosed, fully completed, with each unit/system sent.
Without the fully completed statement, repair/disposal is not possible and delays are unavoidable!
The statement is to be completed and signed by suitably qualified, authorised personnel at the operating organisation.
In the case of shipment to Germany, the statement is to be completed in German or English.
The statement is to be attached to the outside of the packing on shipment.
If necessary, the carrier is to be informed.
1. Product designation (type):
2. Serial number (no. BN):
3. Reason for sending:
4. The unit/system
has not come into contact with hazardous substances. There will be no hazards for personnel or the environment during
repair/disposal. Continue with "6. Legally binding statement"
has come into contact with hazardous substances. Continue with "5. Information on the contamination"
5. Information on the contamination
The unit/system was used in the following application:
and has come into contact with the following classifiable substances or substances presenting a hazard to health/environment:
Trade name:
The unit/system has been emptied in accordance with the operating instructions, flushed and cleaned externally.
Safety data sheets in accordance with the applicable regulations are enclosed (
The following safety precautions are necessary for handling (e.g. personal protective equipment):
6. Legally binding statement
I herewith guarantee that the details specified are true and complete and that I, as signatory, am in a position to judge that this is
so.
We are aware that we are liable to the contractor for any damages arising from incomplete or incorrect specifications. We are
obliged to indemnify the contractor against claims for damages by third parties arising from incomplete or incorrect specifications.
We are aware that, irrespective of this statement, we are directly liable to third parties - in particular including the contractor's
employees tasked with repair/disposal.
Company/institute:
Name, position:
Street:
Post code, city:
Country:
Date, signature:
© Gardner Denver Deutschland GmbH
P.O. box 1510
97605 Bad Neustadt
© Gardner Denver Deutschland GmbH
Chemical designation:
Phone: +49 7622 392 0
Fax: +49 7622 392 300 Internet: www.gd-elmorietschle.com
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Form for statement on safety
(if necessary provide more information on an additional sheet)
Hazardous Properties (e.g. toxic, inflammable,
substance class: caustic, radioactive):
sheet).
Phone:
Fax:
Stamp:
E-mail: er.de@gardnerdenver.com
610.44436.40.000
Edition: 04.2012
English
610.44436.40.000