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SCC-U UTILITY UNIT | OI/SCC-U-EN REV. B
12 Appendix
Return form
Statement on the contamination of devices and components
Repair and/or maintenance work will only be performed on devices and components if a statement form has been completed and
submitted.
Otherwise, the device/component returned may be rejected. This statement form may only be completed and signed by authorized
specialist personnel employed by the operator.
Customer details:
Company:
Address:
Contact person:
Fax:
Device details:
Type:
Reason for the return/description of the defect:
Was this device used in conjunction with substances which pose a threat or risk to health?
Yes
No
If yes, which type of contamination (please place an X next to the applicable items):
biological
toxic
radioactive
Which substances have come into contact with the device?
1.
2.
3.
We hereby state that the devices/components shipped have been cleaned and are free from any dangerous or poisonous substances.
Town/city, date
Telephone:
Email:
corrosive / irritating
explosive
Serial no.:
combustible (highly / extremely
combustible)
other toxic substances
Signature and company stamp
21
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