Producto limpio y descontaminado Gracias por tramitar el formulario.

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Company Name*

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Contact Name*

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Street Address*

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City*

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State*

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Zip/Postal Code*

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RMA#*

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Phone Number*

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Fax Number

Email Address*

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Describe the location or application where the equipment was installed (e.g., golf course, lake, forest, power plant).

Describe the environmental conditions to which the equipment was exposed (e.g., sewer, stagnant water, herbicides, radioactivity).

Did you clean and decontaminate the equipment?

YES Fill out the rest of the form NO, not required. Equipment was used in an environment free from health and safety concerns. Sign document below

Describe how the equipment was cleaned and decontaminated.

List all substances of concern to which the equipment has been, or potentially has been, exposed (attach MSDS sheets, if any).

I hereby certify that the returned equipment has been cleaned and decontaminated according to good industrial practices and is in compliance with relative regulations, or \"as is\" this equipment poses no health or safety risks to the recipient.

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A copy of this form will be sent to the email address listed above.

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