Safety Questionnaire

Procedure for returning vacuum pumps and helium leak detectors
(This questionnaire is only to be filled in and signed by an authorised person)

*Please complete all fields*

Company

Name of Company:
Name of person*:
Position:
Tel no:
Fax no:
e-mail address

*person who filled in this questionnaire

Equipment

Description:
Part numer:
Serial number:
Type of process*:
Date of shipment:

*for which the equipment is used

Service

Service required
(overhaul, repair, etc.):

Failure description:

Copper Process

The product is used on a copper process Yes / No

If "Yes" sealed package and specific labels are required!

Safety Aspect

The above equipment has been in contact with the following substances (name and chemical formula):

These substances present the following risks

If any one answer is "Yes", please provide us with detailed information!

Chemical

Toxic Yes / No

Corrosive Yes / No

Carciogenic Yes / No

Combustible Yes / No

Explosive Yes / No

Biological Yes / No

Radioactive Yes / No

Other Yes / No

Signature

Reminder: You are required to sign the completely filled in form.

Any one or multiple of the above questions for risks have been replied with "Yes"

(protection required)

All of the above questions for risks have been replied with "No"

(No risk)

I confirm that the above equipment has NOT been in contact with any dangerous substances and is free from risk to the service personnel.

Name:
Position:
Date:

You can download your formular now:

Download PDF

Please sign the resulting form and send it to us.

You can change your data with this button:

Further information can be found at:
www.adixen.co.uk
Alcatel Vacuum Technology • 8 Bain Square • Kirkton Campus • Livingston
Tel: 01506 418000 • Fax: 01506 418002 • e-mail: Click here to email us