Declaration of Contamination
Of Freeze Dryers, Vacuum-Concentrators, Centrifuges, Accessories and Vacuum Pumps.
This declaration may only be filled in and signed by authorised staff.
Repair Order dtd. :
Order No. :
Type of unit :
Serial No. :
Type of unit :
Serial No. :
Type of unit :
Serial No. :
Type of unit :
Serial No. :
Accessories :
Is the equipment free from harmful substances ?
YES
Ο
NO
Ο
If not, which substances have come into contact with the equipment?
Name of the substances :
Remarks (e.g. to be touched with gloves only) :
General characteristics of the substances :
Corrosive
Ο
Explosive
Ο
Biologically hazardous
Ο
Radioactive
Ο
Toxic
Ο
Which combination of substances may lead to the development of hazardous materials?
Name of the substances :
Has the equipment been cleaned before shipment?
YES
Ο
NO
Ο
Is the equipment decontaminated and therefore does not pose a health risk?
YES
Ο
NO
Ο
Prior to repair, radioactively contaminated components must be decontaminated according to
the valid regulations for radiation protection.
Legally Binding Declaration
I / we hereby declare that the information on this declaration is correct and complete.
Company / Institute :
Street :
Postcode, City :
Tel. :
FAX :
Name :
Date :
Stamp :
Signature :
Содержание 101041
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