Health and safety clearance form – VACUUBRAND MPT 200 User Manual

Page 18

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Documents are only to be used and distributed completely and unchanged. It is strictly the users´ responsibility to check carefully

the validity of this document with respect to his product. Manual-no.: 999226 // 07/10/2011

Health and safety clearance form

1. Device (Model): ................................................................... 2. Serial no.: .........................................

3. Reason for return / malfunction:

..............................................................................................................................................................

4. Has the device been used in a copper process step (e.g., semiconductor production).

☐ yes ☐ no

5. Substances (gases, liquids, solids) in contact with the device / which have been pumped:

..............................................................................................................................................................

..............................................................................................................................................................

..............................................................................................................................................................

..............................................................................................................................................................

6. Prior to return to the factory the device has been decontaminated.

☐ yes ☐ no

Description of the decontamination method and the test / verification procedure:

..............................................................................................................................................................

..............................................................................................................................................................

7. The device is free of hazardous, harmful substances.

☐ yes ☐ no

8. Protective measures required for VACUUBRAND employees:

..............................................................................................................................................................

9. If the paint is damaged, we wish a repaint or a replacement of parts for reason of appearance (repaint

and replacement at customer’s expense).

☐ yes ☐ no

10. Legally binding declaration

We assure for the returned device that all substances, which have been in contact with the device are

listed in section 5 and that the information is complete and that we have not withheld any information. We

declare that all measures - where applicable - have been taken listed in section “Return to the factory”.

By our signature below, we acknowledge that we accept liability for any damage caused by providing in-

complete or incorrect information and that we shall indemnify VACUUBRAND from any claims as regards

damages from third parties. We are aware that as expressed in § 823 BGB (Public Law Code of Ger-

many) we are directly liable for injuries or damages suffered by third parties, particularly VACUUBRAND

employees occupied with handling/repairing the product.

Shipping of the device must take place according to regulations.

Name: ....................................................................... Signature: ..............................................................

Job title: .................................................................... Company’s seal:

Date: .......................................................................

Release for repair grant by VACUUBRAND (date / signature):

..............................................................

Devices will not be accepted for any handling before we have received this declaration.

Please read and comply with ”Notes on return to the factory”.

Oil filled pumps: Drain oil prior to shipping absolutely!

VACUUBRAND GMBH + CO KG

Alfred-Zippe-Straße 4

97877 Wertheim, Germany

Tel.: +49 9342 808-5660

Fax: +49 9342 808-5666

E-Mail: service@vacuubrand.com

www.vacuubrand.com

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