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Résultat d’examen (cocher):
L’appareil a été contrôlé par un expert
conformément aux spécifications
relatives aux appareils à jet de liquide.
Les anomalies constatées ont été
éliminées de sorte que l’appareil est
dorénavant conforme aux prescriptions
de sécurité du travail.
L’appareil a été contrôlé par un expert
conformément aux spécifications
relatives aux appareils à jet de liquide.
La sécurité du travail ne peut être
assurée qu’après élimination des
anomalies constatées, ceci par le biais
d’une réparation ou d’un échange des
pièces défectueuses.
Lieu, date: ____________________
Signature: _____________________
Procès-verbal d’examen pour nett. HP
concernant le contrôle annuel de la sécurité du travail (Régl. de prév. contre les
accidents) conformément aux spécifications relatives aux appareils à jet de liquide.
(Ce formulaire de contrôle sert de justificatif pour la réalisation des contrôles
réguliers et doit être conservé!)
Propriétaire: _____________________ Type: therm CA Ann.contr.: _________
Adresse: _____________________ N° de série: ______________________
_____________________ N° odre de réparation: _______________
:resilaéràselôrtnoC
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-éR
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)etnatsixe(euqitélangisetteuqalP
)setnatsixe(ecivresedsnoitcurtsnI
n
oitcetorped.sopsid,egallibaH
noisserpsuossetiudnoC
)étiéhcnaté(
)slennoitcnofstnemélE(ertèmonaM
tepalc,ru
ettolfàennaV
)étiéhcnaté(
)egauqraM(noitasirévluP
/noisserpetuahelbixelF
tnemedroccaR
)egauqram/tnemegammo
dnE(
àervuo'séterûsedepapuosaL
noisserprused%02/%01
euqiluardyhruetalumuccA
)étiéhcnaté(tnarubracedetiudn
oC
ennavortcelEelôrtnoC(
)lennoitcnof
tatsomrehT)lennoitcnofelôrtnoC(
).tcnof.rtnoC(tibédedruelôrtnoC
noitat
nemila'delbâC
)tnemegammodnE(
)tnemegammodnE(ehciF
)édroccar(ertuenruetcudnoC
ecnegru'dtêrra'druetpurretn
I
)lennoitcnofelôrtnoC(
têrra/ehcraMruetpurretnI
cesàehcram.céS).tcnof.rtnoC(
sésilituseuqimihcstiudorP
sés
irotuaseuqimihcstiudorP
:elôrtnocedseénnoD
ruelaV
eéveler
-algéR
alàeg
:ruelav
noisserpetuahesuB
srab............ecivresednoisserP
sr
ab............têrra'dnoisserP
..................ssicrionecidnI
ellehcE(
)hcarahcaBed
²OC%.....................²OCruelaV
%...............tnemedneR
erretedruetcudnocudecnatsiséR
:ruelav/.eéss
apédnon
noitalosI
egrahcédedtnaruoC
élliuorrevtelotsiP
Le prochain contrôle régulier conformé-
ment aux spécifications relatives aux
appareils à jet de liquide doit être réalisé au
plus tard avant le:
Mois: ___________ Année:____________
55


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