FOR BLACOH TO ISSUE A RETURN MERCHANDISE  AUTHORIZATION (RMA) NUMBER THE INFORMATION BELOW MUST BE COMPLETED & SUBMITTED. ITEMS RECEIVED WITHOUT AUTHORIZATION WILL BE RETURNED AT YOUR EXPENSE.

SYSTEM  INFORMATION  MUST  BE  COMPLETED  FOR  RETURN  CONSIDERATION Quantity Part # Description Model # Serial # P.O. # Reason for Inspection SYSTEM INFORMATION Type of Pump Charge on SENTRY Unit SENTRY Time in Service Maximum System Pressure Chemicals Pumped Pipe Size Maximum Temperature Flow Rate (GPM) Other notes CUSTOMER INFORMATION Company Contact Address City State Zip Code Phone P.O./Invoice# DISTRIBUTOR INFORMATION Company Contact Address City State Zip Code Phone P.O./Invoice# Evaluation Notes: STATEMENT OF SAFENESS By submitting this form, I certify that I have read a copy of the Material Safety Data Sheet for the process fluid used and that the product being returned has been properly flushed and cleaned of all hazardous materials and does not require any special handling. Name Title