Declaration of decontamination – Yokogawa RotaMASS 3-Series User Manual

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IM 01R04B08-00E-E 1st edition February 15, 2012 -00

<1. INTRODUCTION>

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ROTA YOKOGAWA GmbH & Co. KG
Service & Repair Department
Rheinstraße 8; D - 79664 Wehr
Phone no.: +49 (0)7761-567-190
Fax no.: +49 (0)7761-567-285
e-Mail: [email protected]

Declaration of Decontamination

Legal regulations for the safety of our employees and operating equipment determine that we need
the declaration of decontamination before your order can be handled.
Please make sure to include it with the shipping documents, attached to the outside of the
packaging you use for shipment.

Customer data
Company:

Address:

Contact person:

E-Mail:

Phone no.:

Fax no.:

Reference/Order no.:

Instrument data*
Type:

Serial no.:

Type:

Serial no.:

*If not enough, note on separate sheet

Process data
Process medium:

Medium is:

[ ] toxic
[ ] corrosive
[ ] explosive
[ ] biological hazardous
[ ] unknown if dangerous
[ ] non hazardous

Remarks:

Cleaning agent:

Kind of cleaning :

Other remarks / Reason of return:

We hereby confirm that this statement is filled in completely and truthfully. The returned
instruments were carefully cleaned and are thus free from product residue and dirt. I agree
that if this arrangement does not match with the instruments, they will be sent back to the
above mentioned customer address at our expenses.

Name

Date

Signature