Thermo SORVALL RC-12BP - Page 65

DECONTAMINATION INFORMATION CERTIFICATE
Complete and attach to equipment BEFORE servicing (instructions on reverse)
PLEASE PRINT
CERTIFIED BY _____________________________________________________ TITLE/POSITION ___________________________________________________
PHONE ___________________________ FAX ____________________________ DEPARTMENT _________________________________________________
INSTITUTION _____________________________________________ ADDRESS _________________________________________________________________
CITY _____________________________________________ STATE ____________________________________ ZIP _________________________________
INSTRUMENT ____________________________________________________________________ SERIAL NUMBER _____________________________________
ROTOR _________________________________________________________________________ SERIAL NUMBER _____________________________________
PART ______________________________________________________________________________________ PART NUMBER ___________________________
HAZARDOUS CONTAMINANT(S) ____________________________________________________ DECONTAMINATION DATE ____________________________
DECONTAMINATION METHOD(S) __________________________________________________________________________________________________________
CERTIFIER'S SIGNATURE ___________________________________________________________________________ DATE _____________________________
DECONTAMINATION
DECONTAMINATION
DECONTAMINATION INFORMATION CERTIFICATE
Complete and attach to equipment BEFORE servicing (instructions on reverse)
PLEASE PRINT
CERTIFIED BY _____________________________________________________ TITLE/POSITION ___________________________________________________
PHONE ___________________________ FAX ____________________________ DEPARTMENT _________________________________________________
INSTITUTION _____________________________________________ ADDRESS _________________________________________________________________
CITY _____________________________________________ STATE ____________________________________ ZIP _________________________________
INSTRUMENT ____________________________________________________________________ SERIAL NUMBER _____________________________________
ROTOR _________________________________________________________________________ SERIAL NUMBER _____________________________________
PART ______________________________________________________________________________________ PART NUMBER ___________________________
HAZARDOUS CONTAMINANT(S) ____________________________________________________ DECONTAMINATION DATE ____________________________
DECONTAMINATION METHOD(S) __________________________________________________________________________________________________________
CERTIFIER'S SIGNATURE ___________________________________________________________________________ DATE _____________________________
DECONTAMINATION
DECONTAMINATION
DECONTAMINATION INFORMATION CERTIFICATE
Complete and attach to equipment BEFORE servicing (instructions on reverse)
PLEASE PRINT
CERTIFIED BY _____________________________________________________ TITLE/POSITION ___________________________________________________
PHONE ___________________________ FAX ____________________________ DEPARTMENT _________________________________________________
INSTITUTION _____________________________________________ ADDRESS _________________________________________________________________
CITY _____________________________________________ STATE ____________________________________ ZIP _________________________________
INSTRUMENT ____________________________________________________________________ SERIAL NUMBER _____________________________________
ROTOR _________________________________________________________________________ SERIAL NUMBER _____________________________________
PART ______________________________________________________________________________________ PART NUMBER ___________________________
HAZARDOUS CONTAMINANT(S) ____________________________________________________ DECONTAMINATION DATE ____________________________
DECONTAMINATION METHOD(S) __________________________________________________________________________________________________________
CERTIFIER'S SIGNATURE ___________________________________________________________________________ DATE _____________________________
DECONTAMINATION
DECONTAMINATION