84 AO2000-LS25 LASER ANALYZERS | OI/AO2000-LS25-EN REV. D
18 Appendix
Return form
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:
Device details:
Reason for the return/description of the defect:
Was this device used in conjunction with substances which pose a threat or risk to health?
If yes, which type of contamination (please place an X next to the applicable items):
biological
corrosive / irritating
combustible (highly / extremely
Which substances have come into contact with the device?
We hereby state that the devices/components shipped have been cleaned and are free from any dangerous or poisonous substances.
Signature and company stamp