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Cleaning Certificate
Organization ________________________________
Department _________________________________
Address ___________________________________
City _______________ State ______ Zip ________
Country __________________
Model No. of Device ______ Lot Number _________
Contaminant (if known) _____________________
Cleaning Agent(s) used _____________________
Radioactive Decontamination Certified?
(Answer only if there has been radioactive exposure)
___ Yes ___ No
Cleaning Certified By _________________________
Name
Date
17
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