Goods Return Declaration - GEM 625 Installation, Operating And Maintenance Instructions

Goods return declaration (copy specimen)
Legal regulations for the protection of the environment and personnel require that you include the
completed and signed goods return declaration with your dispatch documents.
If this declaration is not completed or not included with the dispatch documents, your return
will not be processed!
If the valve / device was operated with poisonous, corrosive, flammable, aggressive or water-
endangering media, all medium wetted parts must be emptied carefully, decontaminated and rinsed.
Select an appropriate transport container, label it with the name of media which the valve / device has
been in contact. This serves to avoid personal injury or damage to property from the media remains.
Company details:
Company: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Address: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Contact person: . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Telephone number: . . . . . . . . . . . . . . . . . . . . . . . . .
Fax number: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
E-Mail: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Reason for return:
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Please tick the relevant warning labels:
radioactive explosive
We herewith declare that the returned parts were cleaned and that complying with Danger Protection
Regulations there is no danger from the remains of media for persons or for the environment.
Location, Date . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
corrosive poisonous
35 / 36
Valve / device information:
Type: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Year of manufacture: . . . . . . . . . . . . . . . . . . . . . . . .
Serial number: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Ambient temperature: . . . . . . . . . . . . . . . . . . . . . . . .
Media: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Concentration: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Operating temperature: . . . . . . . . . . . . . . . . . . . . . .
Operating pressure: . . . . . . . . . . . . . . . . . . . . . . . . .
Viscosity: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Solids content: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
harmful bio-
to health hazardous
Stamp / signature . . . . . . . . . . . . . . . . . . . . . . . . . .
oxidising harmless
625_us