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Date:

Customer:

Contact Person:

Contact Phone:

Final Product Destination:

E-mail:

Sleeve Size:

Pipe O.D.:

Temperature:

Working Pressure:

Wall Thickness:

Max. Design Pressure:

Material:

Packing Type:

Pipe Content:

Length Between Seals:

Belly Diameter:

Application:

Rows of Packing:

Underwater Usage?

Depth:

Installation:

External Forces?

Type and Magnitude:

Vents Required (Size/#)?

Sealant Type?

Provided Volume Required?

Anode Required?

Plated Studs & Nuts:

White Marine Epoxy:

Extra Studs & Nuts:

Hinges Required?

Sling Closures:

Extra Packing:

Vert Covers:

Special Materials Required?

Material Certs Required?

Special Tests Required?

Quantity Required

Delivery:

Remarks: