Air Scrubbers USA

Product Query/Quote Please print and Fax to: 952-448-5207

Date: Name of Rep/Account Executive: Company Name: Email: Tel:

1. Space Information

Type of Area Industrial Commercial Retail Office	Space Size ft. long ft. wide square ft.	Ceiling Height ft. high
Usages Manufacturing Warehouse Lab Other:	Fill Factor % estimated percentage of room contents' volume displaced by physical objects	Suspended Ceiling Yes No ft. between ceilings

2. Air Filtration On Premises Information

HVAC Type: # of Units: # of Inlets: # of Returns: Size or Ducts:    Heater/Fan Specs:

Chemicals Chemical Name: by-product of: Chemical Name: by-product of:

Particles Type: PPM: Size: Source: Size: Type: PPM: Size: Source: Size:

Odors Type: Discomfort Level: Strong Medium Mild   Source: Type: Discomfort Level: Strong Medium Mild   Source:

Microbial Viruses Bacteria Mold Allergens Other (Specify Below)    Type: Extent:    Type: Extent:

3. Space Occupant Information

People Number of People:      Functions of People:

4. Space Occupant Information

Materials Explosive Materials: Yes No    Type: Flammable Materials: Yes No    Type: Hazardous Materials: Yes No    Type: MSDS (Material Safety Data Sheets) for sections 2 & 4: Yes No

5. Operational Type

Operation Type Liquid to Vapor Solid to Dust

Point of Discharge Collection Yes No

Duration Per Day: 4 hrs 8 hrs More wk/mo

6. Product Query

Do you have a specific Electrocorp product in mind? Yes   Please specify:        No

7. Process Information

Process Explanation

8. Specific Requirements

Negative Pressure Needed Yes No

Needed by

Budget Yes No Amount:

9. Company Requesting Information

Company Information Company Name: Address: City: Province/State: Country: Contact Person Last Name: First Name: Title: Telephone: Extension: Fax: Email Address:

10. Additional Comments

Process Explanation