Customer Request / Order Sheet

Equipment Type:

Quantity:

Material Type:

Type of Process Connection:

Process Connection Size:

ANSI Rating:

Type of Access Fitting:

Size of Pipeline (inches):

Working PSI/Max PSI:

Velocity:

Working Temp/Max Temp:

Product Type:

Sweet/Sour Service:

%CO2/H2S:

Volume of Product:

Retractable Coupon Holder/Quill

Rod Length (Inches) and Throw:

Type of Valve: ¼” Bleed Valve NACE Rated are Standard:

Type of Coupon:

Rod Cap/T-Handle:

Retrieval Tool:

Type of Quill/Atomizer:

Coupon/Liquid Sampler

Coupon Holder:

Sessile Bacteria Monitor:

Customer Contact Information:

Company:

Contact Person:

Phone:

Fax:

e-mail:

Special Instructions: