Equipment
Manufacturer's Product Name
Manufacturer's Part Number
Manufacturer's Serial Number
If applicable
Tool Identification Number
Tool Manufacturer/OEM
Tool Model
Process
Installed Date
De-installed Date
Part Number of Replacement Equipment
Serial Number of Replacement Equipment
Condition of equipment
We will not accept delivery of any equipment that is contaminated with radioactive substances, biological/ infectious agents, mercury, PCB’s, dioxins or sodium azide. Was your equipment infected by one of these substance ?
PLEASE STOP FILLING THE FORM AND CONTACT OUR TEAM AT INFO@PLASMADIAM
Contamined equipment
Equipment has been used with any substances classified as hazardous under the UN Globally Harmonised System on the classification and labelling of chemicals (GHS), EU Regulation No 1272/2008 on classification, labelling and packaging (CLP) or US Occupational Safety and Health regulations (29CFR1910.1200, Hazard Communication).
Equipment has not been used, or if it has only been used with substances that are not hazardous. It may have been tested, but not connected to any process or production equipment, and only exposed to Nitrogen, Helium or Air.
Condition of equipment What substance your equipment has been infected by ?
Substance
Chemical Symbol
Precautions required (for example, use protective gloves, etc.)
Action required after a spill, leak or exposure
More substance ?
Substance
Chemical Symbol
Precautions required (for example use protective gloves, etc.)
Action required after a spill, leak or exposure
More substance ?
Substance
Chemical Symbol
Precautions required (for example use protective gloves, etc.)
Action required after a spill, leak or exposure
Return information
Reason for return and symptoms of malfunction
For how many hours has the product run ?
Declaration
Name
Job Title
Organisation
Address
Telephone number
Email
Date of equipment delivery
Signature
I have made reasonable enquiry and I have supplied accurate information in this Declaration. I have not withheld any information, and I have followed the Procedure HS2.
Date
Send
