Format No.：A003S1268-01
ULVAC Component Pollution Certificate
This is the certificate to make requests for repairs/inspections of ULVAC's components.
Before sending back your own equipment to us, complete this certificate and submit it to our departments in charge of
your requests or individual sales offices.
Note that for components using toxic gases or to which reactant products adhering to, contact our
departments in charge of your requests or individual sales offices in advance.
Trade name
：
Model
：
S/N
：
Application purpose
：
Details on request:
Fault condition:
Other special notes:
Pollutant (□: Check all that apply)
□ Ensure that the products above are not polluted.
□ The products above are polluted with the following harmful substances.
Pollutant name
(molecular formula)
Characteristics
1
2
3
4
5
To ULVAC, Inc.
Name of contact person
Date: / / /
Customer/Company
name:
Department:
Person in charge:
Sign
TEL
FAX
E-mail
* You are responsible for any accidents attributed to pollutants produced on the way to us. Therefore take special care
in packing the components.
In addition, depending on the pollutants and the polluted conditions, we refuse to do repairs etc. and return
the components to you.
SDS request: Yes/No
Sign for
receipt
Order number
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