Service Safety Certification Form - Qsonica Q700 Operation Manual

Sonicator ultrasonic processor

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SAFETY CERTIFICATION FORM

Items being returned:

______________________________________________________________________________

____________________________________________________________________

Please check only one item below :

___ The equipment w as never used or exposed to any radiological, biological or

chemical agents and is safe to handle, use or dispose of.

___ The equipment w as used but not in conjunction w ith or exposed to any

radiological, geological or chemical agents and is safe to handle, use, or dispose of.

___The equipment w as used in conjunction w ith or exposed to radiological,

biological, or chemical agents and has been decont aminated, rendering it saf er 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

decont amination. Delivery of the equipment can be refused if necessary

documentation is not provided or w here it is determined that the equipment has not

been properly decont aminated. If it is determined that the equipment w as not

properly decontaminated, the Authorized Repair Facilit y reserves the right to bill the

customer for any and all costs associat ed w ith the decontamination and/or

appropriat e disposal of the equipment. In the event the equipment has been

exposed to radiological cont amination, the signature of the Radioactive Safety

Officer is required.

Print name: ___________________________________ RA # ___________________

Signature: ____________________________________ Date: __________________

Rev. 6-12

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