DECLARATION OF DECONTAMINATION

Street Email ZIP, City Fax ... The following equipment has been thoroughly cleaned and is free of hazardous ... The sender is responsible for all dama...

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DECLARATION OF DECONTAMINATION

Legal regulations and the protection of our employees and operating equipment require this signed declaration of decontamination before your order can be processed. Therefore, it is absolutely necessary to send along this statement for any repair or maintenance job. Please fix it outside of the packaging with which you send equipment to us.

1) Information about the sender Company

Phone

Street

Email

ZIP, City

Fax

Your ordern number Responsible contact person

2) The following equipment has been thoroughly cleaned and is free of hazardous residues Device type

Year of construction

Serial No.

Site of operation

3) Which media the device above came in contact?

Gröger & Obst Vertriebs- und Service GmbH Hans-Urmiller-Ring 24 82515 Wolfratshausen

Tel. 08171/997700 [email protected] www.groegerobst.de

Amtsgericht München HRB 14037 Geschäftsführung: Janine Gröger

4) Characteristics of the media listed in section 3: □ toxic to

□ explosive

□ biohazardous

□ corrosive

□ toxic

□ flammable

□ harmful to health

□ radioactive

□ other: Purging and cleaning medium:

- The unit is free from any contamination - The unit does not contain any used filter materials - Condensate containers are empty and rinsed We confirm, to have truthfully completed to the best of our knowledge this declaration completely. The shipment will be in accordance with all laws that apply to the packaging, shipping, and labeling of dangerous substances. The sender is responsible for all damage caused by contamination, not marked decontamination and insufficient decontamination, of the item sent to us, liable.

Name of responsible person in block letters

Company stamp

Title & function

Place, date

Gröger & Obst Vertriebs- und Service GmbH Hans-Urmiller-Ring 24 82515 Wolfratshausen

Signature

Tel. 08171/997700 [email protected] www.groegerobst.de

Amtsgericht München HRB 14037 Geschäftsführung: Janine Gröger