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Vacuum Information Request Form

Help us determine your vacuum needs and for more information, please fill out the form below.

Required Fields *

General Information

Company Name: *
Contact Name: *
Contact Title:
Street Address:
City: *
State:	- Please choose - Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Postal Code:
Country: *
Phone: *
Mobile:
Fax:
Email: *
When/Where Is Equipment Required? *
What Is Your Budget?	Approved? Yes No
Brief Description of Company Activities:

Application

Explain Application:
Current Handling Method:	Manual Brooms Vac Service Small Vacuum Conveyor Being Ignored   Other, explain
	Cleaning Frequency?
	Other comments re current method:
Required Material Conveyance Distance?	Feet: or Meters:
	Any significant vertical rises? Yes No
Required Material Conveyance Rate?
Tell us about your needs:	Design Road Legal Trailer Portable Stationary Power Electric Diesel Liquid Propane Gasoline
Equipment Configuration Restrictions:	Length Width Height Weight
Equipment Location:	Indoor Outdoor
	Describe any hostile elements or required classifications:
	Ambient Temp: Min: Max: Fahrenheit or Celsius
Job Site Elevation:	Feet: or Meters:
Required Material Storage Capacity:	Cubic Feet: or Cubic Yards: or Cubic Meters:
	None Required
Desired Material Disposal Frequency:	Hourly Daily Weekly Continuous Intermittent   Other (Describe)
Discharge Material Into?	None Hopper Truck Drum   Other (Describe)
System Duty Cycle:	Hours/Day Continuous Intermittent
Electrical Requirements:	Volts Phase Cycles NEMA or IP Rating or other requirements
	Weather-resistant Explosion-proof   (Class , Division )
Is Compressed Air Available?	Yes No
	PSI Available CFM Available
Do You Require A Hard Piping System?	Yes No
	Describe any preferences, requirements or limitations:
Required Number of Hose Pick Up Points:	# Maximum open concurrent points
Maximum dBA Sound Level @ 10 ft. (3 m):	Decibels Mandatory or Desirable
	Preferred hose diameter Inches or Millimeters

Material Properties

Material Description:
Bulk Weight:	Lbs/Cubic feet: or Kgs/Cubic meters:
	Other
Product Flowability:	No flow Very flowable
Particle Size:	Min Max Max size is % of total
Moisture % by volume:
Temperature:	Fahrenheit or Celsius
Cohesion:	Slight Extreme
Characteristics:	Hygroscopic Yes Abrasive Yes Explosive Yes Flammable Yes Acidic Yes Corrosive Yes Hazardous Yes Toxic Yes
Material Safety Data Sheet Available:	Yes No
Are other material Characteristics forms available?	Yes No

Other Comments

Comments:
Validation code *