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17 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: Telephone:
Fax: Email:
Device det
ails:
Type: Serial no.:
Reason for the return/description of the defect:
Was this device used in conjunction with substanc
es which pose a threat or risk to health?
F Yes F No
If yes, which type of contamination (please place an X next to the applicable items):
F biological F corrosive / irritating F combustible (highly / extremely
combustible)
F toxic F explosive F other toxic substances
F radioactive
Which su
bstances have come into contact with the device?
1.
2.
3.
We h
ereby state that the devices/components shipped have been cleaned and are free from any dangerous or poisonous substances.
Town/city, date Signature and company stamp
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