Download Decontamination report for Vici

Decontamination Report for VICI® Valves, Detectors and Pumps
For the protection of VICI employees, any items returned to VICI for repair or
evaluation must be accompanied by this completed form. VICI reserves the right to
reject any suspicious packages or those with incomplete documentation. Send items
along with this form and a complete description of the problem to:
Thames Restek UK Ltd
Units 8 & 16 Ministry Wharf
Wycombe Road
Saunderton
Bucks
HP14 4HW
Equipment Identification:
General description: ___________________________________ Serial No. _______
Date of purchase: _______/_______/______
Equipment Condition
Has the item been exposed to harmful substances? YES / NO
If yes, Scientific Name ____________________________________ Liquid/Gaseous
Special Precautions: ________________________________________
If the item has been exposed to more than one potentially harmful substance, please
attach a list of all known harmful substances, including the scientific names and any
precautions associated with the substances.
Were any of the harmful substances:
Explosive
YES / NO
Toxic
YES / NO
Reactive
YES / NO
Has the equipment been decontaminated?
description of the procedure)
Biohazard
YES / NO
Carcinogenic YES / NO
Radioactive YES / NO
NO / YES (if so attach a brief
Customer Information:
Company:
Address:
Phone:
Fax:
Responsible Person:
Job Title:
Signed:
Date:
Email: