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Varec, Inc. 55
4532 Declaration of Contamination Form
B Declaration of Contamination Form
Varec, Inc., an SAIC Company
5834 Peachtree Corners East, Norcross (Atlanta), GA 30092 USA
Tel: +1 (770) 447-9202 Fax: +1 (770) 662-8939
0 G 030
For the safety of our employees and operating equipment, we require that you fill out this form and return it to
Varec with your signature before we can fulfill your order. Please include the completed form with the device and
shipping documents, along with safety sheets and/or specific handling instructions if appropriate.
Warnings for returned device (mark the appropriate symbols)
Company data
I hereby certify that the returned equipment has been cleaned and decontaminated according to standard
industrial practices and is in compliance with all regulations. This equipment poses no health or safety risks due
to contamination.
Type of device/sensor: Serial no.:
Medium/concentration: Temperature: Pressure:
Cleaned with: Conductivity: Viscosity:
radioactive explosive caustic poisonous harmful to
health
biologically
hazardous
inflammable safe
Reason for return
Company Contact person
Department
Address Phone
FAX / e-mail
Order number
Place, date Company stamp and signature
Declaration of Contamination