Redemption Form / Decontamination Certificate - Hermle Z 307 User Manual

Redemption Form / Decontamination Certificate

Decontamination Certificate of Goods Returned upon Delivery
Enclose all returned shipping items and modules necessary!
The complete, full declaration about the decontamination is a prerequisite for the assumption and further processing
of the return. If no corresponding explanation is enclosed, we carry out decontamination with costs at your expense.
Surname; Last Name:
Organization / Company:
Street:
ZIP CODE:
Telephone:
E-Mail:
Pos. Quantity
1
2
3
4
Are the parts listed above in touch with the following substances?
Health endangering watery solutions, buf fers, acids, alkalis:............................
Potentially inf ectious agents: ..................................................................
Organic reagents and solvent: ..................................................................
Radioactive substances: .................................................. α.. β.. γ..
Health endangering proteins: ...................................................................
DNA: ..................................................................................................
Have these substances reached the equipment/assembly? ................................  Yes  No
If so, which ones:
________________________________________________________________
Description of the measures f or the decontamination of the listed parts :
I conf irm the proper decontamination:
Company/Dept ._____________ Place and Date: ____________________________________
Signature of the authorized person: ________________________________________
© Hermle Labortechnik GmbH
_____________________________________
_____________________________________
_____________________________________
_____________ place:____________________
_____________ fax:____________________
_____________________________________
Decontaminated Object
Z307_V1.22_eng
APPENDIX
Serial No. Description/Comment
 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
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