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Declaration of Contamination
The service, repair, and/or disposal of vacuum equipment and components will only be carried out if a correctly completed declaration has
been submitted. Non-completion will result in delay.
This declaration may only be completed (in block letters) and signed by authorized and qualified staff.
Description of product
Type
Article Number
Serial Number
Legally binding declaration:
I/we hereby declare that the information on this form is complete and accurate and that I/we will assume any further costs that may
arise. The contaminated product will be dispatched in accordance with the applicable regulations.
Organization/company
Address
Phone
Email
Name
Date and legally binding signature
This form can be downloaded
from our website.
INFICON GmbH
Bonner Str. 498,50968 Cologne, Germany
Tel: +49 221 56788-112 Fax: +49 221 56788-9112
www.inficon.com [email protected]
68
Puesta fuera de servicio
The product is free of any sub-
stances which are damaging to
yes ‰
health
Harmful substances, gases and/or by-products
Please list all substances, gases, and by-products which the product may have come into contact with:
Trade/product name
Chemical name
(or symbol)
Reason for return
Operating fluid(s) used (Must be drained before shipping.)
Process related contamination of product:
no ‰ 1)
toxic
no ‰ 1)
caustic
no ‰
biological hazard
no ‰
explosive
no ‰
radioactive
other harmful substances no ‰ 1)
1) or not containing any amount
of hazardous residues that
exceed the permissible ex-
posure limits
Precautions associated
with substance
Post code, place
Fax
Company stamp
Copies:
Original for addressee - 1 copy for accompanying documents - 1 copy for file of sender
yes ‰
yes ‰
yes ‰ 2)
yes ‰ 2)
yes ‰ 2)
yes ‰
2) Products thus contami-
nated will not be ac-
cepted without written
evidence of decontami-
nation!
Action if human contact
zisa01e1-b (1106)
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