LME620-AI / PME120-AI / EAN823 / EBN853 / EBN861 ELECTRONIC UNIT | OI/PME/LME/EAN823/EBN853/EBN861-EN REV. E 4114 AppendixReturn formStatement on the contamination of devices and componentsRepair and/or maintenance work will only be performed on devices and components if a statement form has been completed andsubmitted.Otherwise, the device/component returned may be rejected. This statement form may only be completed and signed by authorizedspecialist personnel employed by the operator.Customer details:Company:Address:Contact person: Telephone:Fax: Email:Device details:Type: Serial no.:Reason for the return/description of the defect:Was this device used in conjunction with substances which pose a threat or risk to health? Yes NoIf yes, which type of contamination (please place an X next to the applicable items): biological corrosive / irritating combustible (highly / extremelycombustible) toxic explosive other toxic substances radioactiveWhich substances have come into contact with the device?1.2.3.We hereby state that the devices/components shipped have been cleaned and are free from any dangerous or poisonous substances.Town/city, date Signature and company stampChange from one to two columns