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QSONICA 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. Qsonica reserves the right to refuse delivery of the equipment
without necessary documentation or where we determine they have not been
properly decontaminated. Qsonica reserves the right to bill the customer for any
and all costs associated with the decontamination and/or disposal of the
equipment we determine was not properly decontaminated. In the event the
equipment has been exposed to radiological contamination, the signature of the
Radioactive Safety Officer is required.
Print name: _______________________________ RA# __________________
Signature: _______________________________ Date: __________________
