Declaration of Contamination

This form serves for the submission of your contaminated device. Please make sure to fill in this form as detailed as possible. After having submitted this form, you will receive a summary as PDF which you can add to your device for shipment.

1. Declaration of Contamination of the evaporator

Model and ser.no: Reason for submission (description of error if available): Liquid which was evaporated: aqueous solution of Maximum concentration of the solutions: Other (opt.): Carrier gas used:

Nitrogen/air

Other gas mixtures or gases:

2. Declaration of Contamination of the control unit.

Model and ser.no: Reason for submission (description of error if available): Gases used: Channel 1: Channel 2: Channel 3: Channel 4: Channel 5: Liquid which was evaporated: aqueous solution of Maximum concentration of the solutions: Other (opt.): Carrier gas used:

Nitrogen/air

Other gas mixtures or gases:

3. Contact

Fields marked with * are mandatory.

Company*: Address: Contact person*: Phone*: Fax: Email*:

Location*:

Date*:

I/we hereby confirm that the information provided in this form is correct and complete. The contaminated units will be shipped in compliance with the legal requirements.

By clicking "Submit", I consent to the processing of my personal data in accordance with the Privacy Policy.The data will be used solely for the purpose of providing the product and price information requested by me in accordance with point (b) of Article 5 (1) GDPR. The lawfulness of the data processing is based on point (b) Article 6 (1) GDPR.*