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12. SAFETY CERTIFICATION FORM
Items being returned:
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Please check only one item below:
___ The equipment was never used or exposed to any radiological, biological or
chemical agents and is safe to handle, use or dispose of.
___ The equipment was used but not in conjunction with or exposed to any radiological,
geological or chemical agents and is safe to handle, use, or dispose of.
___The equipment was used in conjunction with or exposed to radiological, biological,
or chemical agents and has been decontaminated, rendering it safer 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
decontamination. Delivery of the equipment can be refused if necessary documentation
is not provided or where it is determined that the equipment has not been properly
decontaminated. If it is determined that the equipment was not properly
decontaminated, the Authorized Repair Facility reserves the right to bill the customer for
any and all costs associated with the decontamination and/or appropriate disposal of
the equipment. In the event the equipment has been exposed to radiological
contamination, the signature of the Radioactive Safety Officer is required.
Print name: ___________________________________ RMA # __________________
Signature: ____________________________________ Date: ___________________
