Instruction Manual
K SERIES Cryostorage System
IM: CryoCeK
Revision: 02
Approved by: CB
Page
70
of
87
Appendix C - CRYO-PRODUCT RETURN INFORMATION FORM
IMPORTANT
: Fill in this form before returning any part of your Worthington Industries Cryostorage
System for repair, maintenance or replacement to Worthington Cylinders GmbH.
Product Information
Material Return Authorization No:
Model No:
Serial No:
Product Stored:
Customer Information
Name:
Email:
Address:
Phone No:
Reason for return
Decontamination Information
Contaminated refrigerators can not be accepted!
Federal law prohibits the transfer of any equipment or products that are contaminated with a radiological,
biological, or chemical waste residue.
Therefore Worthington Cylinders GmbH requests customers to authenticate the following (check one):
A. The equipment was never used.
B. The equipment was not used in conjunction with any radiological, biological, or chemical matter.
C. The equipment was exposed to radiological, biological, or chemical matter, was decontaminated,
and is rendered safe for handling, use, or disposal.
Authorization
By accepting authorization to return this product, the customer assumes all responsibility and liability for
biological, radiological, and chemical decontamination and cleaning. Worthington Cylinders GmbH reserves the
right to refuse delivery of products which in our judgment do not appear to have been properly decontaminated.
We reserve the right to bill the customer for any and all cost associated with the decontamination or disposal of
products which do not appear to have been properly decontaminated. If the product contained radioactive
material, the signature of your radioactive safety officer is required.
Print name:
Signature
Date
NOTE
: Please make a copy of this form for your own records and email original to: [email protected].
Please forward all returns to following address (unless otherwise specified): Worthington Cylinders GmbH,
Attn: Ivana Lapcakova, Beim Flaschenwerk 1, A-3291 Kienberg bei Gaming, AUSTRIA.
