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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: