FORM No: 164

SLA INDUSTRIES
MATERIAL RECYCLING, RECLAIMATION, AND RETURNS
CAUTION: All forms to be filled out correctly and in black, and discrepancies found on official form can lead to further disciplinary action, and in
the event of a private claimant may result in the cancellation of policies held with the company or subsidiaries of.

OPERATIVE/CK/SQUAD/CIVILLIAN NAME: SCL/REP:

ITEM DESCRIPTION / BATCH NO:

FAULT DESCRIPTION / LOCATION IF FOUND:

OFFICE USE ONLY

QUALITY REASSESSMENT Y / N PRODUCTION IMPACT Y / N

TECHNICAL REASSESSMENT Y / N REPUTATION IMPACT Y / N

MAINTENANCE REQUIREMENT Y / N SAFETY IMPACT Y / N

CLAIMANT INSPECTION EVALUATION:

QUALITY REASSESSMENT:

TECHNICAL REASSESSMENT:

MAINTENANCE REQUIREMENTS:

ADMINISTRATIVE SUMMARY :

PAYMENT/ REPLACEMENT

AMOUNT CREDITED: