Refrigerant Removal and Quotation Request

Company: Please enter the name of your company

Date: Invalid format use mm/dd/yy

Name: Please Enter your Name

Phone Number: Enter Your Phone NumberInvalid format use 000-000-0000

Street: Please Enter your street

Fax Number: Invalid format use 000-000-0000

email: Invalid format use MyName@email.comemail is required.

City: Enter City

State: Please select a State.Select a State. Zip: Invalid format use 5 digits

Job Information

Name of Building or Job site

Contact Person:

Phone Number: Enter contact's phone numberInvalid format use 000-000-0000

Address or Location:

City:

State: Please select a State.Select a state.

Zip: Invalid format use 5 digits

Date Requested: Invalid format use mm/dd/yy

What time can we start:

Company Purchase Order:

Complete as much Infomation as Available

1 Serial Number of Unit: Model Number:

2 Manufacture: Seletct The ManufactureSelect The Manufacture

3 Refrigerant: Select Refrigerant TypeSelect Refrigerant Type

4 Factory Charge: Tonnage:

Select one: Air or Water Cooled? Unknown

5 Water Drained: Condenser Yes No Unknown

Evaporator Yes No Unknown

6 Refrigerant Disposition: Please select Disposition.Select Disposition

7 Glycol in System: Select Yes or No or UnknownSelect Yes or No or Unknown Disposal of Glycol Requested: Select Yes or No or Unknown

8 Sump Oil Removal Select Yes or No or UnknownSelect Yes or No or Unknown Sump Oil Disposal Select Yes or No or Unknown.

9 Size of Storage Container Requested: None
Low Pressure	100	200	650
High Pressure	125	240	1000

Additional Information:

Other Information Known About the Job site

1 Loading Dock Available:

Yes

No

Unknown

2 Unit Disposition: Select DispositionSelect Disposition Explain:

3 Refrigerant Lab Analaysis Requested: Yes, No or Unknown?.Yes, No or Unknown Oil Lab Analysis Requested: Yes, No or UnknownYes, No or Unknown

4 Freight Elevator: Yes, No or UnknownYes, No or Unknown Stairs: Yes, No or UnknownYes, No or Unknown How many Flights: Please select a valid item.Please select an item.

5 Location of Unit: Select Unit LocationSelect Unit Location Enter Unit Location: Enter Unit Location

6 Height of the building(in feet): Number of Stories:

7 Parking available : (enough for a 15" box truck) Yes, No or UnknownYes, No or Unknown

8 Electricity: (Two 20 amp connections required) Please select a valid item.Please select an item.

9 Government Base Requirements:

Hold down the Ctrl key to select multiple items.

Other Requirements:

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