Field Page / of Sheet Number Order Origin Basis for Return Customer Dept. Street City Contact Person E-Mail Name Phone Type/Device (Code) Serial Number Delivery Date/Year of Constr. State Yes No Remarks Device was used (operation)? Emptied (medium/means of production)? Please regard in any case! All connections air-sealed? Please regard in any case! Purified (acc. to operating instructions)? Please regard in any case! Purifying agent and method? Remains of medium/harmful to health? Contamination* Chem. Description Commercial Name Characteristics pH-Value > * Please answer explicitly according to material safety data sheet or annex. Devices contaminated with inflammable /explosive, toxic/microbiologic or radioactive materials can only be accepted with the proof of decontamination according to regulations. In case any special safety measures have to be respected when handling the medium, these must be enclosed in the delivery and marked uniquely. According to the legal requirements (WHG, GefStoffV, GGVSE, GGBefG, etc.) the user/client has to ensure for the appropriate safety measures of the handling with hazardous materials. The charged forwarding agent and their representatives are to be instructed about the danger potential. The delivery must be marked regulately. Obligatory Declaration* We herewith confirm, that the data supplied in this form are correct and sufficient to evaluate the contamination. Date Authorised Person > * This declaration may only be filled and verified by authorised qualified staff of the plant operator. Repair/maintenance/recycling can only be executed, if a complete declaration is available otherwise, the acceptance might be refused. A separate declaration has to be filled in for each device Revision No. Revision date First Edition Executed by Released by