HHPC-2 Handheld Airborne Particle Counter Operator Manual

Declared Value/American Manufacturer’s Affidavit
Goods have no commercial value they are being returned for repair/calibration
Date: _______________________
Name of Manufacturer: Hach Ultra Analytics
Address of Manufacturer: 481 California Avenue
Grants Pass, OR 97526
Description of returned articles:________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
I declare that the information given is true and correct to the best of my knowledge and belief.
That the articles described above are the growth, produce or manufacture of the United States
and have been returned to the United States without having been advanced in value or
improved in condition by any process of manufacture or other means, and that no drawback
has, or will be, claimed on such articles. The article was returned for the sole purpose of
repairing/calibration either under warranty or at the expense of the owner. This value of
$______________ is for customs only and has no commercial value.
Name: _______________________________________________________________
Title: ________________________________________________________________
Signature: ____________________________________________________________
RA form 001 for International use only reference RA Procedure 001 Form# 011152 09082003