Please fill out to the best of your knowledge

Attention:

Due to health and safety concerns, ALL PUMPS MUST BE FLUSHED AND NEUTRALIZED PRIOR TO PICK UP

Customer Information:

Date: 

Company Name:

Contact Person:

Mailing Address:

Phone:   Fax:  Email:

Pump and Process Information:

Model:       Size:  3/8" 1/2" 1" 1 1/4" - 1 1/2" 2" 3"      Serial Number:

Wetted Parts:  Select One Aluminum Cast Iron Stainless Steel Hastelloy C Polypropylene Kynar Groundable Acetal Unknown Non-wetted Parts:  Select One Aluminum Cast Iron Stainless Steel Polypropylene Groundable Acetal Teflon Coated Aluminum Nickel Coated Aluminum Unknown     Elastomer Material: Select One Neoprene Buna Viton Nordel Teflon XL Hytral Geolast Unknown

Temp:     Application:      Media:

Does the pump have a filter/regulator installed? Yes     No

Please give a description of the problem: