Specifications

Declaration of Contamination

Of Freeze Dryers, Vacuum-Concentrators, Centrifuges, Accessories and Vacuum Pumps.

This declaration may only be filled in and signed by authorised staff.

Repair Order dtd. :

Order No. :

Type of unit : Serial No. :

Accessories :

Is the equipment free from harmful substances ? YES Ο NO Ο

If not, which substances have come into contact with the equipment?

Name of the substances :

Remarks (e.g. to be touched with gloves only) :

General characteristics of the substances :

Corrosive Ο Explosive Ο

Biologically hazardous Ο Radioactive Ο

Toxic Ο

Which combination of substances may lead to the development of hazardous materials?

Name of the substances :

Has the equipment been cleaned before shipment? YES Ο NO Ο

Is the equipment decontaminated and therefore does not pose a health risk? YES Ο NO Ο

Prior to repair, radioactively contaminated components must be decontaminated according to

the valid regulations for radiation protection.

Legally Binding Declaration

I / we hereby declare that the information on this declaration is correct and complete.

Company / Institute :

Street :

Postcode, City :

Tel. : FAX :

Name :

Date : Stamp :

Signature :