Model No.:A003S1268-03
ULVAC Component Contamination Certificate
This form is used as the Contamination Certificate to make requests for repair/inspection of the ULVAC's
components.
Before sending your equipment to us such as for repair, fill out this form and submit to the contact request or the
representative sales office.
In addition, for the products used for toxic gas or with reaction products adhering, contact the contact
request or the representative sales office in advance
Product Name
：
Model
：
S/N
：
Purpose of Use
：
Detail on Request
(Reason for return,
usage situation,
special notes etc.)
Pollutant (Check all the boxes
(□)
apply)
□
It is ensured that the product above is not polluted by hazardous materials.
□
The product above is polluted by the following hazardous materials.
Pollutant Name (Formula)
Characteristics
1
2
3
4
5
To ULVAC, Inc.
Your representative:
YYYY, MM, DD
Your name / Company
name
Department
Representative:
(signature)
TEL
FAX
* The customer is responsible for any accidents attributed to pollutants caused during the transportation to your
company.
Please take due care. In addition, we are able to refuse repair etc. depending on the pollutants and the polluted
conditions. In such a case, we will send back to you.
Field for ULVAC, Inc.
SDS Request: Yes/No
Receipt
stamp
Order No.
