Vacu-Blot - Biometra

Equipment Decontamination CertificateTo enable us to comply with german law (i.e. §71 StrlSchV, §17 GefStoffV and §19 ChemG) and to avoidexposure to hazardous materials during handling or repair, will you please complete this form, prior to theequipment leaving your laboratoryCOMPANY / INSTITUTEADDRESS______________________________________________________________________________________________________________________________TEL NO _______________________________ FAX NO_______________________________E-MAIL______________________________________________________________________________EQUIPMENT Model Serial No________________________________________________________________________________If on loan / evaluation Start Date: _______________ Finish Date ___________________Hazardous materials used with this equipment___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Method of cleaning / decontamination___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________The equipment has been cleaned and decontaminated:NAME ________________________________(HEAD OF DIV./ DEP./ INSTITUTE / COMPANY)SIGNED ______________________________POSITION ___________________________DATE _______________________________PLEASE RETURN THIS FORM TO BIOMETRA GMBH OR YOUR LOCAL BIOMETRA DISTRIBUTORTOGETHER WITH THE EQUIPMENT.PLEASE ATTACH THIS CERTIFICATE OUTSIDE THE PACKAGING. INSTRUMENTS WITHOUT THISCERTIFICATE ATTACHED WILL BE RETURNED TO SENDER.12