Agilent Technologies TwisTorr Medium Notice De Mode D'emploi page 283

Customer information
Company :
Address:
Equipment
Product description
Failure description
Type of return
Non Billable Billable
Exchange Repair
Health and safety
The product has been exposed to the following substances:
(by selecting 'YES' you MUST complete the table to the right)
Toxic
Harmful
Corrosive
Reactive
Flammable
Explosive (*)
Radioactive (*)
Biological (*)
Oxidizing
Sensitizer
Other dangerous substances
Goods preparation
If you have replied YES to one of the above questions. Has the product been purged?
If yes, which cleaning agent/method:
Has the product been drained from oil?
I confirm to place this declaration on the outside of the shipping box.
I declare that the above information is true and complete to the best of my knowledge and belief.
I understand and agree to the terms and conditions on page 2 of this document.
Name:
Position:
Date:
NOTE: If a product is received at Agilent which is contaminated with a toxic or hazardous material that was not disclosed, the customer will be held
responsible for all costs incurred to ensure the safe handling of the product, and is liable for any harm or injury to Agilent employees as well as to any third
party occurring as a result of exposure to toxic or hazardous materials present in the product.
Agilent PartNo
New PO # (hard copy must be submitted with this form): ______________________________________
Upgrade Demo Calibration
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
Page 3 of 3
Contact Name:
Tel:
Email:
Agilent Serial No
Type of process
(for which the equipment was used)
Evaluation
Substances (please refer to MSDS forms)
* Agilent will not accept delivery of any product that is exposed to radioactive, biological,
explosive substances or dioxins, PCB's without written evidence of decontamination.
Trade name Chemical name
Authorized Signature:
Vacuum Products Division
Request for Return Form
Fax:
Original Purchasing Reference
Return for Credit
Chemical Symbol CAS Number
YES NO
YES NOT APPLICABLE
Agilent VPD Request for Return