Ulvac MBS-053 Instruction Manual page 37

Usage Status Check Sheet (for use in Instruction Manual)
* For the purpose of safety control of repair personnel, fill in within the heavy line frame and
attach the sheet to the item of which repair is requested.
* In case this sheet were not attached or filled in, your request of repair and service may not be
accepted.
* In accordance with the Private Information Protection Law, the provided information will
be used only for determining the cause of failure and whether detoxifying washing should
be conducted. It will never be provided to any third person.
Model Name: _______________
1. Inhaled Gas * Please be sure to fill in.
(1) Whether there is harmful effect on human bodies Yes
(2) Whether there is unusual smell
(3) Type and Name of Gas: ______________________________
* Industrial Safety and Health Law designates particular substances as the materials to
be notified.
2. Usage Status
Operation Method: Approx. ( ) hours per day, ( ) years and ( ) months
□ Continuous Operation
Usage: __________________________________
3. Failure Status □Unusual Noise
□Oil Leakage
4. Detail of Request
5. Others: _____________________________
Company Name:
Address:
Tel:
Agent Name;
Address:
Tel:
* In case you do not have any direct transaction with us, please be sure to fill in the agent
name.
6. Confirmation
The gas and substance used in this pump or unit is harmless to human bodies, or it is not
contaminated by any substance harmful to human bodies.
Signed
* In order to avoid a trouble during transportation, please evacuate oil from any oil pump
before shipping.
* You are requested to ship the package to our Service Division (CS Center). (See the
attached list of addresses.)
Manufacturer's Serial No.:________________
□ Intermittent Operation
Other Symptoms: _______________________________
□Repair (Overhaul)
Personnel in charge:
Fax:
Personnel in charge:
Fax:
No
Yes No
□Abnormal Pressure
□Regular Checks
E-mail:
(seal) Date:
(Sing your name below.)
□Abnormal Actuation