Burkert Type 8709 - Manual

Repair Return Sheet 2011-01-18 / EN_00806066
Phone +49 (0)79 40/10-91 699
Fax
+49 (0)79 40/10-91 490
[email protected]
www.burkert.com
Please complete this form and return in advance by Fax to +49 (0) 7940 / 10-91 490 in order to
receive an equipment return authorisation (ERA) number. No action to repair or examine the product
will be done, until a valid declaration of contamination has been received.
ERA number:
Contact information
Company name + address Contact person
Name:
Phone:
E-mail:
Product information
Type: Id. no.: Serial no.:
Reason for return (e.g. calibration, repair). Please describe in detail.
Contamination information
The product was contaminated with:
poisonous corrosive,
irritant
flammable
hazardous oxidizing cancer-causing,
harmful
explosive environmental
hazardous
nonhazardous
other:
The product was cleaned with:
Packaging and shipping Instructions
•
remove any cables, connectors, separate filters and mounting materials
•
double bag each item in suitable and sealable protective foil
•
transport in suitable shipping container (e.g. original Bürkert shipping container) and include a copy
of this declaration form
•
Please indicate your ERA Number clearly on the outside of the shipping box
By signing this form you are accepting full responsibility for its contents and confirming that any
decontamination has taken place in accordance with legal regulations.
Print name: Date:
Legally valid signature:
Bürkert Werke GmbH
Corporate Quality / Complaint Management
Christian-Bürkert-Straße 13-17
D-74653 Ingelfingen
Germany
DECLARATION OF CONTAMINATION OF PRODUCTS
AND COMPONENTS