Declaration Of Contamination - Homa C237 WF3 Original Instruction Manual

9. Declaration of Contamination

The repair if the instruments can only be accomplished if this document is filled out completely and accurately.
ANSWER by FAX: HOMA Pumpenfabrik GmbH:... +49 (0) 2247 702 - 44
Pump data:
Type:
Part No:
Serial no:
Reason for return:
Contamination of the instruments:
toxic
corrosive
microbiological
explosive
radioactive
other substances
Legally binding declaration:
We hereby certify that the returned parts have been cleaned carefully. To the best of our knowledge, they are
free from any residues in dangerous quantities.
Company:
Street:
Contact person:
Phone:
e-mail:
Date
40
no □ yes □
which substance: __________________
no □ yes □
which substance: __________________
no □ yes □
which substance: __________________
no □ yes □
which substance: __________________
no □ yes □
which substance: __________________
no □ yes □
which substance: __________________
Zip code, City:
Fax:
Company stamp and signature