dynalab

Decontamination Certificate
(* : required information)
 1.  Product Information
Return Authorization Number *
Dynalab Catalog Number
Product Number
  Product Description  
  Use of Product 
 2.  Customer Information
Customer Name *
Title
Address
Account Number
  Phone Number *
 3.  Decontamination Information
Federal law prohibits the transfer of equipment of chemical waste residue. Therefore, we request each customer certifies to the following: (please check one)
The equipment was never used.

The equipment was not used in conjunction with any radiological, biological or chemicals.
The equipment was exposed to radiological, biological or chemicals, and was decontaminated, and is rendered safe for handling use or disposal.
 4.  Authorization
 
Notice: By accepting authorization to return this product, the user assumes all responsibility and liability for biological, chemical and radiological decontamination and cleaning. Dynalab reserves the right to refuse delivery of products which in our judgement do not appear to have been properly decontaminated. Dynalab reserves the right to bill the customer for any and all costs associated with the decontamination or disposal of products which do not appear to have been properly decontaminated. If product contained radioactive material, the signature of the radioactive safety office is required.
Full Name:
  (Authorized Representative)
  Date:
 
 
By Checking this box, I certify that I am me.