Product Cleanliness and Decontamination Your assistance in keeping our employees safe

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It is the policy of Campbell Scientific, Inc., to protect the health of our employees and provide a safe working environment. In support of this policy, Campbell Scientific requires that all products returned for service be (1) clean and (2) uncontaminated by harmful substances, such as hazardous materials, chemicals, insects, and pests.

Use this form to describe the environment from which the equipment was taken, any hazardous substances to which the equipment was exposed, and any cleaning and decontamination processes that were performed.

ANY RETURNS WITHOUT THIS COMPLETED FORM WILL NOT BE PROCESSED. To avoid delays in processing your return, send this form BEFORE your products arrive. Please do not put this form in a box with your returned products. If the form is not received within 5 working days of product receipts, or found to be incomplete, the product will be returned unopened at the sender's expense. Campbell Scientific reserves the right to refuse service on product where specific applications may cause health and safety concerns for its employees.

Thank you for supporting our efforts to protect the health and safety of our employees.

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Please provide the following information:

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 SDS 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.

Signature*

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(sign by typing your name)

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

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