This form is to certify that equipment that might have been contaminated with hazardous substances has been decontaminated before repair or disposal. You must know all of the substances that have been used and produced in the equipment before you complete this form, which must accompany the equipment for repair/removal. |
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Section 1: Equipment |
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Equipment model number |
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Serial Number |
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Plant Number |
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Usual Location |
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Section 2: Substances in Contact with the Equipment |
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Are any of the substances used or produced in the equipment (tick as appropriate):Biologically Active ______ Hazardous Substances ______ Radioactive ______ |
N.B If the item is potentially radioactively contaminated, proof of decontamination must be supplied. |
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Section 3: List of Substances in Contact with the Equipment |
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Substance name or type |
Associated Hazards |
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Section 4: Method of Decontamination |
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Section 5: Declaration |
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Date of Decontamination
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Carried out By (Print Name and give Job Title)
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Contact Details
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Signed |
Date |
Version 2. July 2016
1EQUIPMENT BROUGHT BY THE USERS DESCRIPTIONNAME 2HAS BEEN
2011 CHEVROLET VOLT STANDARD & AVAILABLE EQUIPMENT DESCRIPTION S
230513P---Motor-Requirements-for-HVAC-Equipment-03-07-2022
Tags: certificate of, equipment, certificate, substances, decontamination, hazardous