Please fill out the following data form and fax it to (909) 947-3039

Date______________

Customer__________________________ User: OEM

Address ___________________________ City_______________ State / Zip _____________________

Contact Person______________________ Title_______________

Phone_____________________ Fax_____________________ Distributor_______________________

Customers's General Product Line_______________________________________________________

General Description of Application_____________________________________________

________________________________________________________________

1. Type of Pump: Self-Priming Vacuum________in.Hg/mmHg Lift Suction Flush Suction

2.Type of Valve: 2-way___ 3-Way___ 4-Way___ Other_________ N/C_____ N/I_____ Divertor_____ Other_______

3.Port Size and Type ____________________________________________________________

4. Orifice Equivalent ____________ Inches/Mn Flow Coefficient (Cv) ___________________

5. Operating Pressure ___________ +/- ____ PSIG Air Supply Press.(for Pneumatic Type) _______ PSIG

6. Up-stream Pressure ___________ +/- ____ PSIG Down-stream Pressure ____________ +/- _____PSIG

7. Operating Pressure Differential Maximum _________ +/- ___ PSIG:Minimum ________ +/- ____ PSIG

8. Maximum Flow: (Pump & Valve) Open flow @ ___GPM; Operating Pressure________ +/- _____PSIG@____GPM

Maximum Inlet Pressure _________ +/- ____PSIG Regulated or Relief Pressure _______ +/- _____ PSIG

9. Fluid Temperature __________________ F/C Ambient Temperatire _____________ F/C

Type of Fluid _________________ Spec ____________ Viscosity ____________ SG ___________

10. Vibration __________ Desire Opertaing Life _________Yrs/Mon Life Cycles _____________

11. Physical size limitations:____Inches Wide;____ Inches High ____Inches Deep

12. Voltage __________ AC/DC Cycles (Circle one) 50 60 50/60 Other ___________________

13. Power Nominal Supply __________ Max V; ____________ Min. V ___________ Watts; ____________ Amps (Max)

14. Operating rate ____________ Cycles/Min _________ Hrs/Day; Maximum Number of Consecutive Cycles ________________

15. Service: Continuous Duty _____ Intermittent Duty ______

Max. "ON" Time _______ Hrs./Min./Sec.; Max. "OFF" Time __________ Hrs./Min./Sec.

16. Housing: Pigtail ____ Conduit _____ Explosion-Proof _____ Fume Tight _____ Other _____

Product Required Part No. _____________ Quantity __________ PriceObjective _____________ Delivery Time ____________________

Reply Required By _______________________ Date _____________________________

Unit now being used ______________________ Forecast ___________________/Year

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