Appendix
84 265Dx,
265VS
IM/265D/V-EN-02
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Statement on the contamination of devices and components
Repair and/or maintenance work will only be performed on devices and components if a statement form has been
completed and submitted.
Otherwise, the device/component returned may be rejected. This statement form may only be completed and
signed by authorized specialist personnel employed by the operator.
Customer details:
Company:
Address:
Contact person:
Telephone:
Fax: E-mail:
Device details:
Type: Serial
no.:
Reason for the return/description of the defect:
Was this device used in conjunction with substances which pose a threat or risk to health?
F
Yes
F
No
If yes, which type of contamination (please place an X next to the applicable items)?
Biological
F
Corrosive/irritating
F
Combustible
(highly/extremely
combustible)
F
Toxic
F
Explosive
F
Other
toxic
substances
F
Radioactive
F
Which substances have come into contact with the device?
1.
2.
3.
We hereby state that the devices/components shipped have been cleaned and are free from any dangerous or
poisonous substances.
Town/city, date
Signature and company stamp
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Summary of Contents for 265DS
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