30 QuickSeal
®
Cutter
Appendix
QUICKSEAL® Large Diameter Cutting Tool
Service and Maintenance Request Form
Company Name:
Shipping Address:
Contact Name:
email address:
Phone Number:
Part Number for Service:
Serial Number:
Other General Comments on Condition of Tool:
Purchase Order Number for Repair and Service:
Declaration Concerning the Decontamination and Cleaning of Equipment and Components
To protect our personnel, we require that all equipment or components which come into contact with our
personnel be free of biological, chemical or radioactive contaminants.
Therefore, we can only perform maintenance if:
•
the device has been adequately CLEANED and DECONTAMINATED.
•
this declaration has been filled out, signed and returned to Sartorius
Attention: Please specify exactly the biological,
chemical or radioactive contaminant
The equipment was contaminated with:
Attention: Please describe the cleaning and
decontamination procedure | method
It has been cleaned and decontaminated by:
Legally Binding Declaration
I | we hereby certify that the information provided on this form is true and complete. The equipment and
components have been adequately decontaminated and cleaned according to the legal requirements. No
chemical or biological or radioactive risks remain that could endanger exposed persons' safety or health.
Email Address:
Contact Name:
Title:
Phone Number:
Signature & Date:
We ask for your understanding of our measures to ensure a safe and non-hazardous work environment for
our employees.
Contamination | Cleaning
10.4 Service and Maintenance Request Form