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Customer (End User) Decontamination Declaration
Health and Hazard Safety declaration
To protect the health of our employees and the safety at the workplace, we require that this form is
completed by the user for all products and parts that are returned to us. (Distributors or Service
Organizations cannot sign this form)
NO RMA number will be issued without a completed form. Products or parts returned to our
NY warehouse without a RMA number will be refused at the dock.
A second copy of the completed form must be attached to the outside of the shipping box.
1.
Unit/ component part / type
2.
Serial No.
3.
List any exposure to hazardous liquids, gasses or substances and radioactive material
3.1
List with MSDS sheets attached where available or needed
(if there is not enough space available below, please attach a page):
a)
____________________________________________________________________________
b)
____________________________________________________________________________
c)
____________________________________________________________________________
3.2
Safety measures required for handling the list under 3.1
a)
____________________________________________________________________________
b)
____________________________________________________________________________
c)
____________________________________________________________________________
3.3
Measures to be taken in case of skin contact or release into the atmosphere
a)
____________________________________________________________________________
b)
____________________________________________________________________________
c)
____________________________________________________________________________
d)
____________________________________________________________________________
3.4
Other important information that must be considered
a)
____________________________________________________________________________
b)
____________________________________________________________________________
c)
____________________________________________________________________________
FP (E1.1) 03/2019
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