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16. Clearance certificate form
for ceramus
®
-classic .......................
.........................(SNR) Medium used: .................................................
Yes No Please define in case of YES
Blood, bodily fluids, patholog. samples:
o
o
____________________________
Other hazardous biologic substances:
o
o
____________________________
Biologically-degradable materials which can pose a risk:
o
o
____________________________
Chemicals containing substances harmful to health:
o
o
____________________________
Radioactive materials:
o
o
____________________________
Other hazardous and toxic substances:
o
o
____________________________
We hereby declare that
- the until has been carefully cleaned and decontaminated prior to shipment
- no risks resulting from contamination exist
- we are aware that liability claims can be made against us in the event of damage being caused by contaminated units.
Address of sender:
Name:
___________________________________________________
Date:
___________________________________________________
Signature: ___________________________________________________
