Brodie International
A Brodie Meter Co. LLC Company
www.brodieintl.com
P.O. Box 450 (30459-0450)
19267 Highway 301 North
Statesboro, GA 30461, USA
Phone: +1 (912) 489-0200
Fax: +1 (912) 489-0294
Appendix A
Decontamination Statement
RMA Number: ____________________________________
Item Being Returned: ______________________________
List all chemicals, process fl uids and gases that have come in contact with the equipment, including cleaning
agents. Attach additional pages of information if necessary. A Material Safety Data Sheet (MSDS) is required
if non-food grade products have been used with the item being returned.
Information Required
Product 1
Product 2
Chemical Name
Health and Safety Hazards
Precautions, First Aid
I hereby certify the equipment being returned has been cleaned and decontaminated in accordance with
good industrial practices and in compliance with OSHA and DOT regulations. This equipment poses no health
or safety risks due to contamination.
Signature:______________________________________
Name (Please Print):______________________________
Title:___________________________________________
Company Name:__________________________________
Phone Number:___________________________________
Fax:____________________________________________
E-mail:__________________________________________
Reason for Return:________________________________
REMINDER
All items being returned must be packaged separately. This decontamination statement and the MSDS
sheet(s) must be placed on the outside of the shipping container.
