ISA CBA1000 - Page 42

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Doc. CEI12166 Rev. 1 Pag. 42 Of 47

INSTRUMENT RETURN FORM

DATE ____________ AGENT _________________ COUNTRY ___________________

TYPE OF INSTRUMENT ____________________ SERIAL NO. __________________

INSTRUMENT RETURNED FOR: CALIBRATION ____ REPAIR ____

In case of repair, please specify the following.

DATE OF FAULT _______________ REPORTED BY E-MAIL, PHONE ___________

COMPANY _____________________ USER’S REFERENCE ____________________

FAULT DESCRIPTION ____________________________________________________

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HOW DID IT OCCUR ______________________________________________________

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LOCAL ANALYSIS OR ATTEMPTS TO REPAIR _______________________________

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RECOMMANDATIONS AND NOTES _________________________________________

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