HOSE PRODUCT INQUIRY FORM

Company name Contact

 Address  City

Phone Faxemail

DESCRIPTION AND SERVICE CONDITIONS CHECK LIST

(check all items as applicable)

Size ID         Length      Working/Design Pressure

Operating Temperature             Vacuum? Yes No                       Inches Hg

Material Being Conveyed:

Acid Base    Chemical Drilling Fluid   Dry Air    Fuel     Grain     Oil Sand Slurry    Steel Grit

Steam    Water   Chemical  Chemical Name          Other 

Fluid Properties:

pH =      % Solids =     Concentration

Particle Size:  Lump   Sharp   Round                                    Screen Mesh =

Environmental Considerations:

Indoor    Outdoor   Cold Weather   Ozone   Fluid

Extra Thick Cover Required   Anti Kink Requirement    Bend Radius Required MBR=

End Connections: 

Plain   Capped  Rubber/Duck  Split B/U Rings  Solid B/U Rings  150# Drill  300# Drill

Beaded  Lapped B/U Rings  Swage On  Built in Steel Nipples  Full flow bore

Special Connections  Describe

Special Considerations   Describe

RMA  HAND BUILT LENGTH TOLERANCES::

5' & Under = +/-1", over 5' to 10' = +/- 1.5", over 10' to 20' = +/- 2.5", over 20' = +/-1%