instructions Owner manual

Form for statement on safety

Statement on health safety and on the protection of the environment

 For the safety of our employees and to comply with statutory requirements on handling substances harmful to the health and

the environment, this statement must be enclosed, fully completed, with each unit/system sent.

 Without the fully completed statement, repair/disposal is not possible and delays are unavoidable!

 The statement is to be completed and signed by suitably qualified, authorised personnel at the operating organisation.

 In the case of shipment to Germany, the statement is to be completed in German or English.

 The statement is to be attached to the outside of the packing on shipment.

 If necessary, the carrier is to be informed.

1. Product designation (type):

2. Serial number (no. BN):

3. Reason for sending:

4. The unit/system

has not come into contact with hazardous substances. There will be no hazards for personnel or the environment during

repair/disposal. Continue with "6. Legally binding statement“

has come into contact with hazardous substances. Continue with "5. Information on the contamination“

5. Information on the contamination

(if necessary provide more information on an additional sheet)

The unit/system was used in the following application:

and has come into contact with the following classifiable substances or substances presenting a hazard to health/environment:

Trade name: Chemical designation:

Hazardous

substance class:

Properties (e.g. toxic, inflammable,

caustic, radioactive):

The unit/system has been emptied in accordance with the operating instructions, flushed and cleaned externally.

Safety data sheets in accordance with the applicable regulations are enclosed ( sheet).

The following safety precautions are necessary for handling (e.g. personal protective equipment):

6. Legally binding statement

I herewith guarantee that the details specified are true and complete and that I, as signatory, am in a position to judge that this is

so.

We are aware that we are liable to the contractor for any damages arising from incomplete or incorrect specifications. We are

obliged to indemnify the contractor against claims for damages by third parties arising from incomplete or incorrect specifications.

We are aware that, irrespective of this statement, we are directly liable to third parties - in particular including the contractor's

employees tasked with repair/disposal.

Company/institute:

Name, position: Phone:

Street: Fax:

Post code, city:

Country: Stamp:

Date, signature:

P.O. box 1510 Phone: +49 7622 392 0 E-mail: er.de@gardnerdenver.com Edition: 04.2012

97605 Bad Neustadt Fax: +49 7622 392 300 Internet: www.gd-elmorietschle.com English