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Rev. 3-11

SAFETY CERTIFICATION FORM

Items being returned:

______________________________________________________________________

______________________________

Please check only one item below:

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

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

___ The equipment was used but not in conjunction with or exposed to any radiological,

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

___The equipment was used in conjunction with or exposed to radiological, biological,

or chemical agents and has been decontaminated, rendering it safer 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

decontamination. Delivery of the equipment can be refused if necessary documentation

is not provided or where it is determined that the equipment has not been properly

decontaminated. If it is determined that the equipment was not properly

decontaminated, the Authorized Repair Facility reserves the right to bill the customer for

any and all costs associated with the decontamination and/or appropriate disposal of

the equipment. In the event the equipment has been exposed to radiological

contamination, the signature of the Radioactive Safety Officer is required.

Print name: ___________________________________ RA # ___________________

Signature: ____________________________________ Date: __________________

Qsonica Sonicator User Manual

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