Rev. 6-12
30
SAFETY CERTIFICATION FORM
It ems being returned:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
____________________________________________________________________
Please check only one item below :
___ The equipment w as never used or exposed to any radiological, biological or
chemical agents and is safe to handle, use or dispose of.
___ The equipment w as used but not in conjunction w ith or exposed to any
radiological, geological or chemical agents and is safe to handle, use, or dispose of.
___The equipment w as used in conjunction w ith or exposed to radiological,
biological, or chemical agents and has been decont aminated, rendering it saf er for
handling, use, or disposal.
Authorization
By accepting authorization to return the equipment listed above, the undersigned
assumes all responsibility and liability for radiological, biological and chemical
decont amination. Delivery of the equipment can be refused if necessary
documentation is not provided or w here it is determined that the equipment has not
been properly decont aminated. If it is determined that the equipment w as not
properly decontaminated, the Authorized Repair Facilit y reserves the right to bill the
customer for any and all costs associat ed w ith the decontamination and/or
appropriat e disposal of the equipment. In the event the equipment has been
exposed to radiological cont amination, the signature of the Radioactive Safety
Officer is required.
Print name: ___________________________________ RA # ___________________
Signature: ____________________________________ Date: __________________
Summary of Contents for Sonicator Q700
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