DECONTAMINATION CERTIFICATION

RMA #:801

I, the undersigned employee of , certify that all decontamination and safety procedures described in the White Knight Decontamination Instructions document have been followedfor the return of the product listed below.

Serial Number

Serial Number New

Pump Type

Failure Details
Maintenance Shaft Seal problem Shuttle problem Fluid leak Air leak Bellows problem Other

Contact Information (to send evaluation report to)

Name

Email (required)

Equipment ID

Fluid Flow Pump Number(1,2,..)

Equipment Type (main/sub)
Main Equipment Sub Equipment

Metal Exposure:

Product was NOT used in a Metal Process
Product was used in a Copper Metal Proces
Product was used in another Metal Process (Non-Copper)

Chemical Exposure:

Product was NOT used in chemicals (DI water only)
Product was used in chemicals

I confirm that I agree with the terms