Reclamation Shipping Form

SHIPPING FORM

CUSTOMER DECLARATION

OF CONTAMINANTS

Please complete this form and return it to Inland Vacuum’s customer service department, so that we may expedite and safely reclaim your vacuum pump fluid. Please return via fax (585)-293-3093 , e-mail; info@inlandvacuum.com, as packing slip with shipment, or mail to :

Inland Vacuum Industries, Inc.

35 Howard Avenue P.O.Box 373

Churchville, NY 14428 - 0373

Attn: Customer Service Dept.

Product Information:

Description / Name : _____________________________________________________

List all substances, gases, chemicals, and by-products which may have come in contact with this fluid.

_______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________

Was fluid used in a Semiconductor Copper process? Yes / No

Was fluid ever exposed to, or contaminated with toxic, hazardous, or otherwise chemicals? Yes / No

Examples of contamination:

__Toxic Materials __Corrosive Materials

__Carcinogen __Biological Substances

__Oxidizer __Radioactive Materials

__Flammable Materials __Combustible Materials

If yes to any of the above questions, and fluid has been exposed to the above materials Inland will not accept fluid for reclamation.

If a fluid is received at Inland in a contaminated condition, to ensure the fluid’s safe handling the customer will be held responsible for all costs incurred. The customer will also be liable for any harm or injury to Inland employees, and will indemnify and hold harmless Inland from damages due to injury to Inland employees, its agents or any other person or entity, resulting from exposure to toxic or hazardous materials present in fluid.

Company Information:

Name: ______ _________________________________

Address: _______________________________________

City: ________________ State: _____________ Zip: _________

Contact: ______ _________________________________

E-mail Address: ________________________________________

Phone: ______________________

Fax: ______________________

Return Authorization Information:

RA#: _________________ PO#: _____________________

Please call (585)-293-3330 with any concerns or questions. To protect our employees from injury by exposure to harmful materials, the accuracy and completeness of this form is imperative. Thank you for your cooperation.