Varec 4532 manual Declaration of Contamination Form

4532 Declaration of Contamination Form

B Declaration of Contamination Form

Declaration of Contamination

For the safety of our employees and operating equipment, we require that you fill out this form and return it to Varec with your signature before we can fulfill your order. Please include the completed form with the device and shipping documents, along with safety sheets and/or specific handling instructions if appropriate.

Type of device/sensor:	Serial no.:
Medium/concentration:	Temperature:	Pressure:
Cleaned with:	Conductivity:	Viscosity:

Warnings for returned device (mark the appropriate symbols)

radioactive	explosive	caustic	poisonous	harmful to	biologically	inflammable	safe
				health	hazardous

Reason for return

Company data
Company	Contact person
	Department
Address	Phone
	FAX / e-mail
	Order number

I hereby certify that the returned equipment has been cleaned and decontaminated according to standard industrial practices and is in compliance with all regulations. This equipment poses no health or safety risks due to contamination.

Place, date Company stamp and signature

Varec, Inc., an SAIC Company

5834 Peachtree Corners East, Norcross (Atlanta), GA 30092 USA

Tel: +1 (770) 447-9202 Fax: +1 (770) 662-8939

Varec, Inc. 55