R E Q U E ST F O R R E T U R N RA# ___________
Health and Safety Form
1. Return authorization numbers (RA#) will not be issued for any product until this Certificate is completed and returned to Kurt J.
Lesker Company (KJLC) Returns and Service Representative (Fax 412-233-6105). For pump repair questions contact Vacuum
Services at 412-387-9200 x7277. For other product questions call 412-387-9200.
2. When the form has been received and approved, the customer will be contacted and given a return authorization number.
3. Goods must be packaged properly to maintain vacuum cleanliness and prevent shipping damage. Items being returned for credit
must be: as new and in re-stockable condition; returned in original packaging; and include any manuals and cabling originally
provided. Items returned for credit are subject to a restocking fee. Pumps returned for repair must have oil drained, inlet port sealed,
and exhaust port sealed. Please ensure that shipment documentation and package label clearly show assigned return authorization
number (RA#). KJLC cannot accept any return without this reference, and reserves the right to return the item to the sender at the
sender鈥檚 expense.
Return all items to this address: Kurt J. Lesker Company, Attn: RA# _________ 1515 Worthington Avenue, Clairton, PA 15025
4.
5. If a product is received at KJLC in a contaminated condition, the customer will be held responsible for all costs incurred to ensure
the product鈥檚 safe handling. The customer will also be liable for any harm or injury to KJLC employees, and will indemnify and hold
harmless KJLC from damages due to injury to KJLC employees, its agents or any other person or entity, resulting from exposure to
toxic or hazardous materials present in the product. Equipment that has been exposed to radioactive or biological substances
will not be accepted.
I. DESCRIPTION:
Equipment Type:_______________________________________________________________________________
Quantity: _____Model No.: ______________________ Serial No.:________________________________________
Original Sales-order number: ____________________ Original PO#: _____________________________________
II. REASON FOR RETURN (Be Specific):
_____________________________________________________________________________________________
_____________________________________________________________________________________________
III. WAS THE PRODUCT EVER EXPOSED TO, OR DID IT EVER CONTAIN TOXIC, HAZARDOUS, OR OTHERWISE HARMFUL
CHEMICALS? YES ______ NO ______
If yes, properly identify such materials by checking the appropriate box(s) below. A MSDS Sheet must be supplied for
each box that is checked.
u Toxic Materials u Radioactive Materials
u Corrosive Materials u Biological/Infectious Substances
u Carcinogen u Flammable/Combustible Materials
u Oxidizer u Other ______________________
u Yes u No
Used in a Semiconductor Copper process?
If Yes was checked in Section III:
1. The product must be cleaned or decontaminated and made safe to handle before returning to KJLC.
2. The Health and Safety Form and Documentation showing proof of cleaning and/or decontamination must be returned to
KJLC鈥檚 R.A. Coordinator for review and approval.
I hereby certify that the product mentioned in Section I of this form has been properly cleaned or decontaminated and is
safe to handle.
Name _______________________________ Position _________________________________________
Signature _______________________________ Date ____________________________________________
Phone _______________________________ Fax _____________________________________________
Company _______________________________
KJLC approval that product was properly cleaned or decontaminated.
Signature _______________________________ Date: _________________________
We rely on the accuracy and completeness of this information to protect our employees from injury by exposure to
harmful materials. Thank you for your cooperation.
Form Number QAF-206 Rev. A 8-22-03
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