Company Name*

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Title

Department

Address

Address 2

City

State

Arizona Alaska Arizona Arkansas California Colorado Connecticut Delaware 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

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Quantity Required

Liquid

Concentration (%)

Capacity/Flow Rate

GPM GPH MPH LPH

Discharge Pressure

PSI FEET BAR

Oper. Temp

C   F
Min: Max:

Corrosive

Flammable

Yes No

SP. GR.

Vapor Pressure (psi)

Viscosity

CPS SSU CS

NPSHA (feet)

Sanitary

Yes No

Suction Pressure (psi)

Abrasive

Yes No

Duty Cycle

0-8 Hours 8-16 Hours 24 Hours

Solids

Yes No

Solid Type

Delivery Date Required

Type of Motor

ODP TEFC XP Chem Duty

Voltage

110 240 230/460 208 Other

Phase

1 3

Frequency

60 50

AC or DC