Redemption Form: Decontamination Certificate - Hermle Z 287 A Operating Manual

APPENDIX

Redemption Form: Decontamination Certificate

Decontamination Certificate of Goods Returned Upon Delivery
Enclose all returned shipping items and modules necessary!
The completely full declaration about the decontamination is 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 Decontaminated Object
1
2
3
4
Are the parts listed above in touch with the following substances?
Health endangering watery solutions, buffers, acids, alkalis:....................... .....
Potentially infectious 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 for the decontamination of the listed parts:
I confirm the proper decontamination:
Company/Dept ._____________ Place and Date: ______________________________
Signature of the authorized person: ________________________________________
© Hermle Labortechnik GmbH
_____________________________________
_____________________________________
_____________________________________
_____________ place: __________________
_____________ fax: ____________________
_____________________________________
Serial No.
Z287A_V1.19
_eng
Description / Comment
 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Yes  No

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