CENTURY LABS II CORPORATION

Health and Safety Form

For our fax form version, click here.

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Manufacturer:
Email Address:
Part Number:
Serial Number:
Has this equipment been used?	No - New unit. Yes - Used only with clean, dry inert gas (For example: Air, N2, Ar, He). Yes - Used with solvents or oils. Yes - Used with chemicals, non-inert gases, biological or radioactive agents. Yes - Used in a Semiconductor Copper process.
If selection above is yes, please identify all materials:
Has equipment been purged?	Yes No
If yes, purged with what?
Has equipment been flushed?	Yes No
If yes, flushed with what?
Has equipment been decontaminated?	Yes No
If yes, explain process:
Required service and/or detailed failure information:
Your Company Name:
Contact Phone number:

CLC II will not accept delivery of equipment that has been chemically, radioactively or biologically contaminated, without written evidence of decontamination. We will require evidence that the biological process is not harmful.