vacuubrand ME 16C NT VARIO o.C. Instructions For Use Manual

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vacuubrand ME 16C NT VARIO o.C. Instructions For Use Manual Manual pdf 92 page image

page 92 of 96Health and safety clearance formHealth and safety clearance form1. 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 ☐ no5. Substances (gases, liquids, solids, biological material, e. g. bacteria, viruses) in contact with the device /which have been pumped:................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................6. Risk level of the used biological material: ☐ none ☐ 1 ☐ 2* ☐ 3** ☐ 4*** Contact the VACUUBRAND service absolutely before dispatching the device.** Devices which have been in contact with biological substances of risk level 3 or 4 cannot be checked, main-tained or repaired. Also decontaminated devices must not returned to VACUUBRAND due to a residual risk.7. Radioactive contamination: ☐ yes ☐ no8. Prior to return to the factory the device has been decontaminated: ☐ yes ☐ noDescription of the decontamination method and the test / verification procedure:........................................................................................................................................................................................................................................................................................................................................................9. All parts of the device are free of hazardous, harmful substances: ☐ yes ☐ no10.Protective measures required for service staff:............................................................................................................................................................................11. 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 ☐ no12.Legally binding declarationWe assure for the returned device that all substances, which have been in contact with the device are listed insection 5 and that the information is complete and that we have not withheld any information. We declare that allmeasures - where applicable - have been taken listed in section “Repair - Maintenance - Return - Calibration”.By our signature below, we acknowledge that we accept liability for any damage caused by providing incom-plete or incorrect information and that we shall indemnify VACUUBRAND from any claims as regards damagesfrom third parties. We are aware that as expressed in § 823 BGB (Public Law Code of Germany) we are directlyliable for injuries or damages suffered by third parties, particularly VACUUBRAND employees occupied withhandling/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) : ...................................................................................................................Protective measures: ☐ Protective gloves, safety goggles ☐ Hood ☐ External cleaningVACUUBRAND GMBH + CO KGAlfred-Zippe-Straße 497877 Wertheim - GermanyT +49 9342 808-5660 F +49 9342 808-5666E-Mail: service@vacuubrand.comwww.vacuubrand.com