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E n g l i s h
Appendix 4 Form for final delivery of Store H2O
Dik Geurts
The Netherlands
Form for final delivery of Store H2O
Build-in date:
Client:
…………………………………..
Street:
………………………………….. House number:
……………………………..
Postal code:
………………………………….. City:
……………………………..
Chimney height:
……………………….….m
Cross-section:
…………………………m
Material:
…………………………….
Hood?, if so, which type:
…………………………..
Height above ridge?
…………....……………..m
Valve?:
…………………………..
Cleaning possibilities:
……………………………..
Air supply:
………………………………
Ø CH connection:
…………………………mm
Pump unit (obligatory)
………………………………..
Ø water connection:
…………………………mm
Control temperature pump unit
…………………………….°C
Declaration of delivery:
Firm stamp:
The user hereby declares that the appliance
has been delivered in working order and that
he/she was explained how to use and
maintain the appliance:
Date and signature user:
Date and signature installer:
Dik Geurts
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