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Appendix A
Certificate of Decontamination
Name:______________________________________________________
Address:______________________________________________________
Telephone / Fax:_________________________________________________
Device:__________________ No.: __________________________
A) I confirm that the returned items are not contaminated with liquid, toxic,
carcinogenic or radioactive substances or any other harmful substances.
B) I confirm that the returned items have been decontaminated and can be processed
without affecting the health of the personnel.
Materials used: Che Biology·Radioactivity*
Contamination
specific
information:____________________________________________
___________________________________________________________
Decontamination
procedure
1
:________________________________________________
___________________________________________________________
Date and place:_______________________________________________
Signature:_____________________________________________________
Name (Capital)_____________________________________________
*) When the device is used with radioactive materials, the signature of a radiation
safety officer is also required.
This device has been certified by the following signatory to be free of radioactive
contamination.
Date and place:________________________________________________
Signature:______________________________________________________
Name (Capital)____________________________________________
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1 Including the decontamination reagent used.